Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthetic agent(s) and/or steroid injections coded 64447 and 64450 provided on November 26, 2019.

You asked the Plan to pay for the anesthetic agent(s) and/or steroid injections. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.

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 codes 64447 and 64450 are not supported in the medical record. Specifically, the operative report did not include documentation of anesthetic agent(s) and/or steroid; other peripheral nerve or branch; therefore, code 64450 cannot be verified. The operative report did not include documentation of anesthetic agent(s) and/or steroid; femoral nerve; therefore, code 64447 cannot be verified. 

Based on this information, we decided that Medicare rules for coverage of the anesthetic agent(s) and/or steroid injections have not been met. Therefore, we decided that the Plan does not have to pay for the anesthetic agent(s) and/or steroid injections coded 64447 and 64450 provided on November 26, 2019.
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 requested admission to a SNF is medically necessary. The Plan denied your request. The Plan says rules for SNF care have not been met.
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 you are a 66-year-old female with lung cancer with brain metastases and seizure disorder. While there are identifiable skilled therapy service needs, there are no identifiable skilled nursing service needs. In addition, you do not require skilled nursing or therapy services on a daily basis and do not meet severity of illness or intensity of service criteria for 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 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: 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 IRF care is medically necessary for the enrollee's condition. 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 the enrollee is a 66-year-old male who was admitted to the acute care hospital on April 15, 2021, after a fall. In this case, the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require, or to be able to currently tolerate, fifteen hours per week of rehabilitative services with regular physician evaluation. The enrollee's care needs can be met at a lower level of care. 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.
You asked the Plan to pre-approve SNF care. You say that the enrollee would benefit from physical and occupational therapies. The Plan denied your request. The Plan says rules for SNF care have not been met.
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 that, based on the documentation provided, the enrollee does not have documented skilled nursing or skilled therapy needs. The enrollee appears to be functioning at or near baseline. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs at this point are custodial. 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 SNF care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the continuous glucose monitor and supplies (K0553 and K0554) provided on September 29, 2020, through November 2, 2020.

You asked the Plan to pay for the continuous glucose monitors and supplies. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted did not indicate the provider discussed the need for the billed supply code; therefore, the billed supply code cannot be verified.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results.

We looked at the file and Medicare rules. The documentation submitted does not include any clinical information to verify if the member performs blood glucose testing at least four times per day, uses insulin with at least three daily injections, and requires frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of the continuous glucose monitors and supplies have not been met. Therefore, we decided that the Plan does not have to pay for the continuous glucose monitor and supplies (K0553 and K0554) provided on September 29, 2020, through November 2, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the continuous glucose monitor and supplies (K0553 and K0554) provided on November 19, 2020.
You asked the Plan to pay for the continuous glucose monitor and supplies. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not indicate the provider discussed the need for the billed supply codes; therefore, the billed supply codes cannot be verified.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results.
We looked at the file and Medicare rules. The documentation does not indicate that the enrollee performs blood glucose testing at least four times per day, uses insulin with at least three daily injections, and requires frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of the continuous glucose monitor and supplies have not been met. Therefore, we decided that the Plan does not have to pay for the continuous glucose monitor and supplies (K0553 and K0554) provided on November 19, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee meets criteria for the LTACH services. The Plan denied your request. The Plan says rules for the LTACH services have not been met.
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 that, based on the documentation provided, the enrollee is currently receiving care in a nursing home. A request has been made to admit the enrollee to the LTACH to treat a chronic sacral ulcer. If the enrollee is need of inpatient care for the ulcer (surgical debridement, intravenous antibiotics) she should be admitted to an acute care hospital for such treatment. Direct admission to the LTACH is not medically necessary or reasonable. 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 the LTACH services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance services (HCPCS A0425 and A0427) provided to the enrollee on September 11, 2020.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says this was not billed correctly.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. 

We find that HCPCS codes A0425 and A0427 are not supported in the medical record. Specifically, the diagnosis code that was billed on the claim for these codes missing the laterality detail. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for ambulance services (HCPCS A0425 and A0427) provided to the enrollee on September 11, 2020.
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 LTACH care is medically necessary. The Plan denied your request. The Plan says the rules for LTACH care have not been met.
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 a 69-year-old male who was admitted to the acute care hospital on April 3, 2021, following a stroke. The enrollee is tolerating ventilator weaning. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and acute care hospitals (ACH) 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 LTC 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: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a PET-CT scan (78816).
You asked the Plan to pre-approve a PET-CT scan. You say that the requested service is necessary for the enrollee. The Plan denied your request. The Plan says that the PET-CT has no advantage over a regular CT scan in this case.
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 a PET-CT scan. Our reviewer says that the requested service is medically necessary. Our physician reviewer found that the enrollee has a history of head and neck cancer and is on immunotherapy for progressive disease. The enrollee had a PET-CT in January 2021 and a follow-up PET-CT has been ordered. Our reviewer found that the requested PET-CT as a subsequent treatment strategy meets criteria for coverage per the Medicare rules. 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 PET-CT scan have been met. Therefore, we decided that the Plan has to pre-approve a PET-CT scan (78816).
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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa (J7323).
You asked the Plan to pre-approve Euflexxa. You say that the enrollee has failed the cortisone injection. The Plan denied your request. The Plan says the enrollee has stage IV osteoarthritis of the knee. The Plan says that this is a contraindication to the requested injection. The Plan also says that the requested injection is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved 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 Euflexxa. Our reviewer says that the requested Euflexxa injection is not medically necessary. Our physician reviewer found the Plan's criteria for Euflexxa has not been met. The reviewer found there is no documentation of at least 2 different drugs for osteoarthritis being used. The reviewer found there is also no documentation of a recent trial of physical therapy for knee pain. Therefore, the reviewer found that the requested Euflexxa injection is 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 Euflexxa have not been met. Therefore, we decided that the Plan does not have to pre-approve Euflexxa (J7323).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the air ambulance services provided on December 10, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not medically necessary.
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your medical condition is such that transportation by ground ambulance is not appropriate. 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 the services. Our reviewer says that the requested air ambulance services are not medically reasonable and necessary. Our physician reviewer found that the documentation does not support that the enrollee could not be transported by other means besides air ambulance. Ground ambulance or other means of transportation such as stretcher or wheelchair van would have been appropriate and safe. The documentation does not show that the enrollee required faster transportation than ground transport could provide, or that there would have been a threat to the safety of the patient by using ground transportation options. The documentation did not support that the transferring hospital did not have adequate facilities to provide the needed medical 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 the services have not been met. Therefore, we decided that the Plan does not have to pay for the air ambulance services provided on December 10, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy, 30 minutes with patient, provided on
August 10, 2020, by an OON provider.

You asked the Plan to pay for the practitioner service. You say that the service was medically necessary. The
Plan denied your request. The Plan says prior authorization was not obtained before the service was rendered to
the enrollee. The Plan says there are multiple in network providers available. The Plan also says that the service
was not urgent or emergent.

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 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 the psychotherapy, 30 minutes with patient,
provided on August 10, 2020, by an OON provider.
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 the enrollee meets medical management criteria and needs physician oversight. The Plan denied your request. The Plan says the denial of authorization for IRF service is correct.
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 enrollee's nursing, medical, and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the records support 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 the enrollee 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care
after April 16, 2021.
You asked the Plan to pre-approve the continuation of SNF. You say that you continue to need SNF care. The
Plan denied your request. The Plan says rules for SNF care are no longer met.
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 the continuation of SNF. Our reviewer
says that daily skilled services are not necessary. Our physician reviewer found you are an 81-year-old female
with gastrointestinal bleed. In this case, there are no identifiable skilled nursing service needs and no
identifiable skilled therapy service needs. In addition, you do not require skilled nursing or therapy services on
a daily basis and do not meet severity of illness or intensity of service criteria for 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 the continuation of SNF have not been met. Therefore, we decided that the Plan
does not have to pre-approve the continuation of skilled nursing facility (SNF) care after April 16, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided from November 24, 2020, to December 29, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this provider does not hold a Medicare approved license.
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program. Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for the services provided from November 24, 2020, to December 29, 2020.