Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet joint injections (64493, 64494, 64495).
You asked the Plan to pre-approve facet joint injections (64493, 64494, 64495). You say that the requested
facet joint injections are medically necessary. The Plan denied your request. The Plan says the enrollee does
not meet criteria for the requested facet joint injections.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve facet joint injections (64493, 64494,
64495). Our reviewer says that the enrollee does not meet criteria for the requested facet joint injections. Our
physician reviewer found the enrollee has chronic low back pain with radiation. He has failed back surgery
syndrome with lumbar radiculopathy and has a SCS in place. He is taking Norco, Tylenol and Gabapentin for
pain. He has had several epidural steroid injections without significant pain relief.
The LCD criteria preclude facet blocks when there is another probable pain generator. Here the enrollee has
degenerative disc disease and lumbar radiculopathy. Therefore, the request is not medically reasonable or
necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of facet joint injections (64493, 64494, 64495) have not been met. Therefore, we
decided that the Plan does not have to pre-approve facet joint injections (64493, 64494, 64495).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveProtonix tab for the enrollee.You asked the Planto pre-approvethe tab. You say that this is medically necessary.The Plandenied your request. The Plansaysthis medication is a benefit exclusion.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plandoes not haveto pre-approveProtonix tab for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that the requested admission to a LTACH is medically necessary.The Plan denied your request. The Plan says the requested admission to a LTACH is not medically necessary.The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested admission to a LTACH is not medically necessary. Our physician reviewer found for this enrollee, admission for a small bowel obstruction led to complications following surgery where they required mechanical ventilation and pressors. Current documentation describes the enrollee stable on ventilation with tracheostomy and is being gradually weaned from pressor support. Although ongoing acute care iscertainly needed in this situation, it was not clear from the notes if the enrollee had reached the maximal medical improvement for the conditions needing acute care treatment to determine if at least 25 days or more of LTACH would be needed. Perhaps withmore time receiving treatment at the current setting, this will be more clear. There were no proposed and needed treatments or services at the LTACH which were not already being provided and covered at the current acute care facility. Therefore, this request for LTACH services will be considered not medically necessary at this time.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Planto pre-approveIRF care. You say that it is felt that an acute rehab stay would be beneficial.The Plandenied your request. The Plansaysthe enrollee does not require acute care and can be managed with less intensive therapy services.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee was admitted to the hospital after a fall. She is legally blind and suffered no fractures. She has pain and lung nodules which are being investigated. MD notes indicated that because of her blindness and pain, she is to be discharged to an SNF. No other medical problems are managed in the acute care.Based on review of the available records, the patient does not meet criteria for IRF admission. The patient was medically stable except for pain and lung nodules with no evidence of need for supervision by PMR Physician or needs acute rehab nursing care. She may benefit from further PT and an OT but does not require an intensive therapy program. IRF admission is not medically necessary based on her medical stability.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met.Therefore, we decided that the Plandoes not haveto pre-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the inpatient services provided on June 5, 2019 to June 8, 2019
You asked the Plan to pay for the inpatient services. You say that the services were preauthorized. The Plan denied your request. The Plan says that services were elective and not preauthorized.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The record shows that the plan provided authorization for the services at issue. Therefore, we decided that the Plan has to pay for the inpatient services provided on June 5, 2019 to June 8, 2019
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) and a knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on July 30, 2019.
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) and a knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on July 30, 2019.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approvea PositronEmission Tomography (PET) Scan (78815).You asked the Plan to pre-approvethe PET scan. You say that the service is medically necessary.The Plan denied your request. The Plan says that rules for coverage have not been met.The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the PET scan. Our reviewer says that the PET scan is medically necessary. Our physician reviewer found the enrollee's physician suspects malignancy. The PET scan is appropriate at this time.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the PET scan have been met.Therefore, we decided that the Plan has to pre-approvea Positron Emission Tomography (PET) Scan (78815).If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the newinformation. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Orthovisc.
You asked the Plan to pre-approve Orthovisc. You say that the requested Orthovisc is medically necessary. The Plan denied your request. The Plan says the enrollee must try and fail Gel-One or Synvisc/Synvisc-One first.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Orthovisc. Our reviewer says that the Plan's step therapy criteria have not been met. Our physician reviewer found the enrollee is with knee pain and a diagnosis of right knee osteoarthritis, confirmed by x-rays. The Plan requires a trial of drugs Gel-One or Synvisc/Synvisc-One first before they will approve the requested drug, Orthovisc. The provided medical records do not indicate that the enrollee has tried and failed the required drugs. The provided medical records do not indicate that the Plan's required drugs would likely be less effective and/or likely have adverse effects for the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Orthovisc have not been met. Therefore, we decided that the Plan does not have to pre-approve Orthovisc.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the records provided support the need for
LTACH care. The Plan denied your request. The Plan says the guidelines for coverage of LTACH care have
not been met. The Plan says that the enrollee's medical condition is not stable
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found the enrollee is currently undergoing treatment at an acute care hospital (ACH) for
presumed endocarditis and progressive renal failure. The enrollee is receiving a prolonged course of antibiotics
and has been started on hemodialysis. The enrollee is not intubated/ventilated. There is no evidence that the
enrollee requires services that are not currently available. There is no advantage in transferring the enrollee to
the LTACH. The enrollee can remain at the current ACH until such a time that no acute services are required.
The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care needs.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for whole body PET imaging (78813), a CT scan of the abdomen and pelvis (74176), a CT scan of soft tissue of the neck (70490) and a CT scan of the thorax (71250) provided on July 26, 2019.
You asked the Plan to pay for the PET imaging and CT scans. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the records submitted do not support the services billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code 78816, 74176, 70490 and 71250 is not supported in the record. Specifically, the records submitted do not include the actual date of service that these procedures were rendered. There is insufficient information to determine whether payment is due and the amount of payment. Based on this information, we decided that Medicare rules for coverage of the PET imaging and CT scans have not been met. Therefore, we decided that the Plan does not have to pay for whole body PET imaging (78813), a CT scan of the abdomen and pelvis (74176), a CT scan of soft tissue of the neck (70490) and a CT scan of the thorax (71250) provided on July 26, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says the services could be provided in another setting.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is currently undergoing treatment at an ACH following surgery or a toxic megacolon. The enrollee is not intubated/ventilated. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care needs. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveKetamine injections.You asked the Planto pre-approvethe injections. You say that this is medically necessary.The Plandenied your request. The Plansayspain and depression are not accepted indications for this request.The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the injections. Our reviewer says that the requested injection is not medically reasonable or necessary. Our physician reviewer found Esketamine is the only form of Ketamine that is approved to treat depression. The use of Ketamine intravenous to treat pain and depression would be off-label. Therefore, the request of Ketamine is considered medically unreasonable and unnecessary.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the injections have not been met.Therefore, we decided that the Plandoes not haveto pre-approveKetamine injections.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your
request. The Plan says needs can be met at an alternate level of care, such as outpatient therapy.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described above.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found the complexity of your nursing, medical and rehabilitation needs do not require an
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does
not reveal that your medical status requires the intensity of an IRF stay with close physician or nursing
supervision. You may benefit and participate in additional therapy of PT and OT but the documentation does
not support that you require or can tolerate this on an intensive rehabilitation facility therapy program level in
an IRF.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve admission to an inpatient rehabilitation facility (IRF).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 2, 2019 by an out of network (OON) provider.
You asked the Plan to pay for laboratory testing. You say that you are requesting that the Plan process and pay this claim. The Plan denied your request. The Plan says he denial of payment for these services is correct, because this provider is out-of-network with the Plan and the ordering physician is also out-of-network with the Plan.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the medical services provided on July 2, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on September 24, 2019.
You asked the Plan to pay for the pump assembly and operation. You say that it takes 30 minutes to set up the machine and the perfusionist is required to remain in the operation room during the length or the procedure. The Plan denied your request. The Plan says payment for this service is the responsibility of the facility to any vendor.
The Plan must follow Medicare rules. Medicare rules say that Medicare does not pay any provider or supplier other than the facility or hospital for services furnished to the beneficiary while an inpatient.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the pump assembly and operation have not been met. Specifically, payment for this service is included in the DRG payment to the facility. Therefore, we decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on September 24, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora lumbar-sacral orthosis (L0650) provided to the enrollee on October 29, 2019.You asked the Plan to pay forthe orthosis. You say that the claim should be paid.The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.A review of the file does not show that the telehealth service was provided in an authorized originating site. Thismeans that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered.Therefore, we decided that the Plan does not have to pay fora lumbar-sacral orthosis (L0650) provided to the enrollee on October 29, 2019.