Persius/hicric huggingface dataset:
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pre-approve transthoracic echocardiography with doppler complete for the enrollee.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says that this has not been established as standard of care.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 services. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has a known left bundle branch block (LBBB) and has not been re-evaluated in the past two years. She is not very active to conclusively assess dyspnea symptoms. LBBB can be an early manifestation of an underlying developing cardiomyopathy with higher risk for the development of congestive heart failure and higher mortality. Periodic reassessment of left ventricular function is medically reasonable to assess for asymptomatic deterioration of function which would necessitate significant changes in medical or other therapies (i.e. AICD, bi-ventricular pacemaker). This therefore meets the applicable rule section 1862(a) for medical reasonableness and necessity. 

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 services have been met. Therefore, we decided that the Plan has to pre-approve transthoracic echocardiography with doppler complete for the enrollee.

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 new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

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 the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for respiratory failure and COVID 19 pneumonia. Medical problems are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided 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 acute IRF admission and services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).

You asked the Plan to pre-approve SNF admission. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you are currently in an inpatient rehabilitation facility. You have stable vital signs. You had routine chronic foley catheter care. You required stand-by to contact guard/minimal assistance with functional mobility including walking to 132 feet with a rolling walker. The documentation does not support that you require the specialized skill, knowledge and judgment of a skilled professional nurse required to safely and effectively provide medically necessary and reasonable treatment. As a practical matter, you do not require the necessary services on an inpatient basis, in a skilled nursing facility setting. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).v
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that you need IRF care. The Plan denied your request. The Plan says rules for IRF care have not been met.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

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 you are a 77-year-old male with a past medical history of diabetes and end stage renal disease who presented to an acute hospital on February 24, 2021, with a perforated viscus. You were later transferred on April 2, 2021, to a long-term acute care hospital for further care. Based on the medical records provided the complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Although you require physical therapy and occupational therapy services, based on the medical records provided you do not require an intensive inpatient rehabilitation therapy program. Finally, there is concern that you will not be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility due to your level of weakness and disability. In this case, care at the skilled nursing facility level appears to be appropriate. 

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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve the CardioMEMS device (CPT code 33289), for the enrollee.

You asked the Plan to pre-approve the CardioMEMS device. You say that the enrollee needs this procedure due to their worsening heart failure. The Plan denied your request. The Plan says that the services are considered experimental and investigational.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 CardioMEMS device. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has complex cardiopulmonary disease with HFpEF (2), ongoing Class III Congestive Heart Failure (CHF), and it has been very difficult to manage her fluid status and diuretics with conventional measurements of weight, renal function testing and physical exam. The enrollee remains very symptomatic and requires frequent follow-up with intravenous (IV) outpatient diuresis and supplemental oxygen therapy. Given the complex regimen and the inability to manage the enrollee's fluid status with conventional methods, published data suggest the enrollee would benefit from more precise measurement of pulmonary filling pressures to prevent rehospitalization, improve her quality of life as well as their heart failure symptoms and heart failure class. Cardiomems pulmonary pressure monitoring device implantation in this enrollee would likely benefit the enrollee's management and has published data and expert opinion to recommend its use in this type of situation (1,2,3,4). It would not be considered investigational and based on the applicable CMS Section 1862(a) criteria Cardiomems would be considered medically necessary, appropriate and reasonable for use in this clinical situation. 

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 CardioMEMS device have been met. Therefore, we decided that the Plan has to pre-approve the CardioMEMS device (CPT code 33289), for the enrollee.

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 new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an occlusal guard (D9944).

You asked the Plan to pre-approve the occlusal guard. You say that you need a new guard because your current one does not fit. The Plan denied your request. The Plan says this service exceeds the maximum count allowed per period.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, occlusal guard (D9944) is limited to one procedure every three plan years. The record shows that you received an occlusal guard (D9944) on June 24, 2020 and your occlusal guard (D9944) benefit has been exhausted. Therefore, we decided that the Plan does not have to pre-approve an occlusal guard (D9944).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a Skilled Nursing Facility (SNF).

You asked the Plan to pre-approve SNF care. You say that the enrollee cannot go home because of an investigation at the current SNF. The Plan denied your request. The Plan says the denial of authorization for SNF care is correct.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a Skilled Nursing Facility (SNF) setting. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a Skilled Nursing Facility (SNF).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa.

You asked the Plan to pre-approve Euflexxa. You say that you would like the plan to reconsider their denial The Plan denied your request. The Plan says Euflexxa is not medically necessary.

The Plan follows Medicare rules. Medicare rules say that Euflexxa is only covered for certain indications. 

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 Euflexxa. Our reviewer says that the documentation does not support that Euflexxa is medically reasonable or necessary. Our physician reviewer found you have been diagnosed with osteoarthritis of the ankle. The review indicates that the FDA has approved hyaluronans for the treatment of pain associated with osteoarthritis of the knee and have been recognized as a therapeutic option in osteoarthritis of the shoulder. There is no clinical rationale for the use of Euflexxa for osteoarthritis of the ankle. The clinical value and effectiveness of Euflexxa in the setting of ankle arthritis have not been demonstrated. Therefore, you do not meet criteria for the requested services. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have to pre-approve Euflexxa.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable controller (E2311, E2377, E2313).

You asked the Plan to pre-approve an expandable controller. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee can control the power options through their own switches.

The Plan follows Medicare rules. Medicare rules say that an expandable controller is covered when it is medically necessary for a function described in the LCD. 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 an expandable controller. Our reviewer says that based on the medical records provided, there is no documentation that the requested expandable controller is medically necessary. Our physician reviewer found the enrollee has sufficient bilateral upper extremity strength and is independent with eating and upper body dressing. This indicates that she has adequate strength and dexterity to operate the power options with their own switches. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an expandable controller have not been met. Therefore, we decided that the Plan does not have to pre-approve an expandable controller (E2311, E2377, E2313).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on November 9, 2020, by an OON
provider.

You asked the Plan to pay for lab work. You say that you would like this claim reprocessed and paid. The Plan
denied your request. The Plan says prior authorization was not obtained by the member's primary care
physician.

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 had network providers
available who could have provided 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 lab work provided on November 9, 2020, by an
OON provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ozempic, 0.25 to 0.5 mg dose pen.

You asked the Plan to pre-approve the self-administered drug. You say that the medication is medically necessary. You say that the enrollee has had increased numbers and dizziness. The Plan denied your request. The Plan says the requested drug is considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the requested drug is not covered under Medicare Part B.

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 Plan does not have to pre-approve Ozempic, 0.25 to 0.5 mg dose pen.

Benefits for the self-administered drug may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.

You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says large population sufficiently-powered randomized controlled trials that demonstrate long-term health outcome advantages are needed.

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 the device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the device is experimental. More research is needed to show safety and efficacy of the device. 

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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve extracorporeal shockwave therapy.

You asked the Plan to pre-approve the therapy. You say that this is medically necessary. The Plan denied your
request. The Plan says this is not a standard treatment for erectile dysfunction.

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 the therapy. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found low-intensity extracorporeal shock wave therapy (Li-ESWT) is considered an experimental treatment for
erectile dysfunction. In general, the evidence evaluating the safety and efficacy of ESWT for erectile
dysfunction consists of case series with relatively small sample sizes and short-term follow-up. These studies
have yielded inconsistent results.

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 therapy have not been met. Therefore, we decided that the Plan does not
have to pre-approve extracorporeal shockwave therapy.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex Superion device placement surgery (22869, 22870).

You asked the Plan to pre-approve the Vertiflex device. You say that you hope for a favorable outcome to approve this preauthorization request and provide the necessary coverage that the enrollee should be entitled to. The Plan denied your request. The Plan says Vertiflex is investigational and experimental and the enrollee is not receiving this device as part of a Medicare covered clinical trial. There is not enough studies on Vertiflex Superion to show it is safe and effective.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Vertiflex device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex Superion device placement surgery (22869, 22870).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on September 21, 2020.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the testing is not covered.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed above, are not covered.

The test at issue in this appeal, a cardiovascular risk assessment panel, was requested solely for screening
purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan
does not have to pay for the laboratory services rendered on September 21, 2020.