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

We decided that the Plan has to pre-approve an arthroscopy (79879).
You asked the Plan to pre-approve the arthroscopy. You say that this surgery is medically necessary for the
treatment of the member's condition. The Plan denied your request. The Plan says that this service is not
medically necessary.
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 arthroscopy. Our reviewer says that
the requested items/services are considered medically reasonable and necessary in this case. Our physician
reviewer found current evidence based medical literature would support surgical intervention in this enrollee's
clinical scenario of on-going pain and significant mechanical symptoms interfering with activities of daily
living. The orthopedic surgeon has reported findings of loose body and clinical exam findings document
positive meniscal signs.
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 arthroscopy have been met. Therefore, we decided that the Plan has to preapprove
an arthroscopy (79879).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion of an interlaminar stabilization device (Superion Vertiflex).
You asked the Plan to pre-approve Vertiflex procedure. You say that you are appealing with medical records. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because there is not enough medical evidence that shows this procedure 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 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 Vertiflex procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found Vertiflex is still considered an experimental/investigational procedure because of a lack of a fully powered prospective randomized trial that is compared with open decompression. The rate of re-operation is also a concern. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Vertiflex procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve insertion of an interlaminar stabilization device (Superion Vertiflex).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Provox tracheostomy supplies (A4626, A4245, A4481, A4456).
You asked the Plan to pre-approve Provox tracheostomy supplies. You say that the enrollee requires the Provox tracheostomy supplies. The Plan denied your request. The Plan says based on the documentation provided, the enrollee is able to use tracheostomy supplies that an in network provider can supply.
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 Provox tracheostomy supplies. Our reviewer says that the requested items are not considered medically reasonable and necessary in this case. Our physician reviewer found in the case of this enrollee, there was no documentation provided which justifies brand specific supplies, namely Provox brand, would be needed for safety and effectiveness in caring for their tracheostomy. The prescribing physician states that they have no preference in brand name, but would accept the insurances proposal. Therefore, although tracheostomy supplies are needed, the brand specific supplies will be considered not medically 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 Provox tracheostomy supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve Provox tracheostomy supplies (A4626, A4245, A4481, A4456).
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Retacrit.
You asked the Plan to pre-approve Retacrit. You say that the requested Retacrit is medically necessary. The
Plan denied your request. The Plan says that the requested Retacrit is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDAapproved
drugs if they are medically accepted as safe and effective or appropriate for the particular use.
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 Retacrit. Our reviewer says that the
requested Retacrit is medically necessary. Our physician reviewer found the enrollee is scheduled for type B
thoracic aorta dissection repair. This enrollee is a Jehovah's Witness and refuses blood transfusion with
baseline mild anemia and a planned aortic surgery. Retacrit carries non-FDA major compendia support as a red
blood cell transfusion refusal (substitute). Retacrit is a standard treatment to improve the hb/hct prior to
surgery. The service is reasonable and medically necessary for the enrollee in this case.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Retacrit have been met. Therefore, we decided that the Plan has to pre-approve
Retacrit.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve RFA (64625). You asked the Plan to pre-approve the RFA. You say that you would like reconsideration because you are in a great amount of pain. The Plan denied your request. The Plan says this service is not medically necessary when performed at the sacral level.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 RFA. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this service is considered experimental/ investigational because of the wide variation in efficacy reported in the peer reviewed literature.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 RFA have not been met. Therefore, we decided that the Plan does not have to pre-approve RFA (64625).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that an IRF admission is medically necessary. The Plan
denied your request. The Plan says an IRF admission 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 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 that based upon the review of available records, the enrollee with a recent above the
knee amputation (AKA) and encephalopathy does not meet criteria for coverage of an IRF admission. The
patient is not following commands with medical issues that require attention by the acute medical team. While
he may benefit from continuing physical and occupational therapy, there is no evidence of a need for an
intensive therapy program with therapy 3 hours per day. The enrollee's condition is not appropriate for an IRF
admission as he cannot participate in or endure therapies to benefit from them.
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 an acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a FreeStyle Libre continuous glucose monitoring system.You asked the Plan to pre-approve a continuous glucose monitor. You say that your physician thinks a continuous glucose monitor will work for you.The Plan denied your request. The Plan says the record shows you are not insulin treated with three or more daily injections of insulin or use an insulin pump.The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered only when they are medically reasonable and necessary and replace a blood glucose monitor.We looked at the file and Medicare rules. Criteria for a continuous glucose monitor have not been met. Based on this information, we decided that Medicare rules for coverage of a continuous glucose monitor have not been met.Therefore, we decided that the Plan does not have to pre-approve a FreeStyle Libre continuous glucose monitoring system.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Tecentriq (J9022).
You asked the Plan to pre-approve Tecentriq. You say that the requested medication is necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not been met.
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 Tecentriq. Our reviewer says that the medication is not medically necessary. Our physician reviewer found the review has determined that the documentation does not support that the Tecentriq is medically reasonable and necessary for the enrollee. The documentation does not support that the Tecentriq is safe and effective 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 Tecentriq have not been met. Therefore, we decided that the Plan does not have to pre-approve Tecentriq (J9022).
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided October 9, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that services were medically necessary.
The Plan denied your request. The Plan says that the inpatient services were not medically necessary and were
not preauthorized.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases,
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or
more.
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 pay for acute inpatient hospital care. Our reviewer
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician
reviewer found the review has determined that the record showed that at the time of inpatient admission the
admitting physician reasonably expected that the patient's necessary hospital care (including earlier ED and/or
observation care) would span two midnights. There were delays in transfer arrangements and transferring the
enrollee to a plan facility was not appropriate at the 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 acute inpatient hospital care have been met. Therefore, we decided that the Plan
has to pay for the acute inpatient hospital care provided October 9, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services provided to the enrollee on May 9, 2019 and billed under code 80307. You asked the Plan to pay for this testing. You say that this claim should be paid. The Plan denied your request. The Plan says the physician documentation is incomplete and does not establish medical necessity. The Plan must follow Medicare rules. Medicare has specific documentation requirements for this type of testing. The physicians order and the medical records must specifically show how this testing will be used to treat illness or disease present in the enrollee at the time of service as opposed to this testing being done for screening purposes. Based on the records provided, the required Medicare criteria are not met. Therefore, we decided that the Plan does not have to pay for drug testing provided to the enrollee. Therefore, we decided that the Plan does not have to pay for drug testing services provided to the enrollee on May 9, 2019 and billed under
code 80307.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xiidra 5% Eye Drops.
You asked the Plan to pre-approve self-administered drugs. You say that these eye drops are medically
necessary. The Plan denied your request. The Plan says these eye drops are not covered under Medicare Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 Xiidra 5% Eye Drops.
Benefits for self-administered drugs 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: Imaging
Decision: Favorable

We decided that the Plan has to pay for the EKG interpretation provided on August 9, 2019.You asked the Plan to pay for the EKG interpretation. You say that this was incorrectly denied as duplicate since multiple providers interpreted several EKGs on the date of service.The Plan denied your request. The Plan says that the use of modifier 77 is not valid here as it was the same physician that performed the repeated service.The Plan must follow Medicare rules.The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan has not provided sufficient information to support the denial. We lack a copy of either the claim or the provider remittance advice. The Plan indicates that there was an incorrect modifier used; however, other than the Plan's statement we are able to evaluate what modifiers were used. It appears that modifier -77 would be appropriate as multiple EKGs were provided on the same date, not all of which were provided by the appealing provider. Without clear information showing what was billed on this claim, we find that the denial rationale is not supported.Therefore, we decided that the Plan has to pay for the EKG interpretation provided on August 9, 2019.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: SNF
Decision: Favorable

We decided that the Plan has to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that you are requesting a reconsideration of the Plan's
denial. The Plan denied your request. The Plan says that the enrollee does not meet criteria for coverage of a
skilled nursing facility admission.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed above 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 the
enrollee meets criteria for coverage of inpatient skilled nursing facility care. Our physician reviewer found the
member requires both skilled nursing and therapy services on a daily basis. He is unable to perform essential
activities of daily living such as bed mobility or transfer without assistance. He is unable to safely maintain his
right lower extremity weightbearing precaution as he has a periprosthetic fracture. The member's condition
would be expected to deteriorate with services provided on a less than daily basis. The member had previously
been able to function at a modified independent level. There is a reasonable expectation of a reduction in
burden of care with a goal of a successful return to the community through the SNF level care being requested.
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 been met. The Plan must continue coverage for the SNF skilled
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing
facility (SNF) care.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an injection of non-compounded foam sclerosant
(36466).
You asked the Plan to pre-approve the sclerotherapy. You say that you would like reconsideration based on the
records submitted. The Plan denied your request. The Plan says it is unknown if the member remains
significantly symptomatic following the lower extremity sclerotherapy treatment.
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 sclerotherapy. Our reviewer says
that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found there is no documentation that the member continues to have activity limiting
symptoms despite the treatments already rendered.
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 sclerotherapy have not been met. Therefore, we decided that the Plan does
not have to pre-approve an injection of non-compounded foam sclerosant (36466).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on September 20, 2019.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your
request. The Plan says the enrollee did not have prior authorization for out of network care and there were
insufficient records provided to support this testing was medically necessary.
The Plan must follow Medicare rules. The rules say that Plans can require enrollees to get prior authorization.
The Plan states providers must submit records that show the services billed were medically necessary. The
enrollee did not have prior authorization and the records provided do not show specific medical necessity for
this testing. Therefore, we decided that the Plan does not have to pay for lab services provided to the enrollee
on September 20, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre 14 day sensor.
You asked the Plan to pre-approve a Freestyle Libre 14 day sensor. You say that the item is necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered only when they are medically reasonable and necessary and replace a blood glucose monitor. 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 a Freestyle Libre 14 day sensor. Our reviewer says that the item is not medically necessary. Our physician reviewer found the criteria calls for CGM when you are adjusting insulin doses according to blood glucose levels, are taking 3 shots per day of insulin, and are checking blood glucose levels 4 times per day. These criteria have not been met. This does not mean that CGM/libre would not benefit you, but merely that the Medicare criteria for coverage are not met. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a Freestyle Libre 14 day sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre 14 day sensor.