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

We decided that the Plan does not have to pre-approve varicose vein treatment using sclerotherapy.

You asked the Plan to pre-approve varicose vein treatment using sclerotherapy. You say that varicose vein treatment using sclerotherapy is medically necessary. The Plan denied your request. The Plan says Medicare does not consider the treatment of truncal veins with sclerotherapy to be medically necessary. In addition, these veins are larger than what Medicare allows for sclerotherapy.

The Plan follows Medicare rules. Medicare rules say that sclerotherapy for vessels larger than 4 mm in diameter considered not medically reasonable or necessary and are denied as such. 

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 varicose vein treatment using sclerotherapy. Our reviewer says that the requested sclerotherapy is not medically reasonable and necessary. Our physician reviewer found the Medicare Local Coverage Determination states, in relevant part, that the following interventional treatments are not considered medically reasonable or necessary and are denied as such: Sclerotherapy for vessels larger than 4 mm in diameter and sclerotherapy for large, extensive or truncal varicosities. In this case, the record indicates that the enrollee previously was treated with endovascular ablation. The enrollee is a Clinical-Etiological-Anatomical-Pathophysiological (CEAP) class 3 and has symptoms of varicosities as well as dermatitis and stasis. The Plan has denied sclerotherapy for truncal varicosities. The prescriber has requested coverage for sclerotherapy of truncal varicosities and for varicosities of 4 mm greater in diameter. The coverage criteria for these services are not satisfied. The requested coverage for sclerotherapy cannot be recommended. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of varicose vein treatment using sclerotherapy have not been met. Therefore, we decided that the Plan does not have to pre-approve varicose vein treatment using sclerotherapy.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care from May 29, 2021.

You asked the Plan to pre-approve the SNF care. The Plan denied your request. The Plan says the enrollee no longer needs SNF care.

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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee does not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment in a SNF beyond the last covered date. The documentation does not reveal evidence of complex wound care, new enteral feedings, or other skilled nursing SNF need beyond the last covered date. The enrollee's functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment in a SNF beyond the last covered date. The enrollee does not require skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis" in a SNF. As a practical matter, this enrollee does not require the necessary services on an inpatient basis, in a skilled nursing facility setting beyond the last covered date. 

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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care from May 29, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the psychotherapy services (90832) provided on February 5, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for the psychotherapy services. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says that prior authorization was not obtained for these services rendered by an OON provider.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that you can choose to receive care from out-of-network providers. The plan will cover services from either network or out-of-network providers, as long as the services are covered benefits and are medically necessary. 

The provider in this case is not a network provider with the Plan. However, the Plan contract states that enrollees can choose to receive care from out-of-network providers. The Plan will cover these services as long as they are covered benefits that are medically necessary. Additionally, the Plan contract states that the enrollee does not need to get a referral or prior authorization when receiving care from an out-of-network provider. Therefore, we decided that the Plan has to pay for the psychotherapy services (90832) provided on February 5, 2021, by an out-of-network (OON) provider.

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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Intracept procedure for the enrollee.
You asked the Plan to pre-approve these services. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says that the clinical value and effectiveness of the Intracept procedure in the setting of low back pain has not been demonstrated in the peer-reviewed literature.
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 these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Detailed documentation is evident of additional (plausible pain-generating) pathology in the lumbar spine. MRI demonstrated retrolisthesis L2 on L3 with herniated disc extending caudad, slightly to the right creating mild right canal stenosis at L3, along with pathology demonstrated at multiple other lumbar levels. A request was also made for a lumbar interlaminar epidural steroid injection at levels L5/S1 with sedation. Therefore, multiple other plausible pain generators including at the lumbosacral spine are evident. Basivertebral nerves/vertebrogenic pain is not reasonably identified as the sole and/or primary source of pain. Furthermore, there is limited published, large-scale, long-term peer-reviewed literature that shows the request to be an effective and/or safe treatment for the noted pathology. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve the Intracept procedure for the enrollee.
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 have already been sent home from the hospital and were readmitted within a week. You cannot function on your own and require additional care. The Plan denied your request. The Plan says the records show that it is not reasonable to expect that you will be able to fully participate in and benefit from the intensity of services at an IRF. The necessary skilled nursing and therapy services can safely be provided in a different setting.

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 that the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do require physical and occupational therapy, but there is no documented need for an intensive rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Medically necessary services can be provided in a different 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: 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 your nursing, medical and rehabilitation needs does not require an
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for a
witnessed cardiac arrest. Medical conditions are stable. There are no complex nursing or rehabilitation needs.
You do not require treatment by multiple therapies, including either physical therapy or occupational therapy,
and an intensive rehabilitation therapy program. You do require physical and occupational therapy but there is
no documented need for an intensive rehabilitation program.

Medically necessary services can be provided in a different level of care. There is not a reasonable expectation
that you 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: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve use of Alimta.

You asked the Plan to pre-approve Alimta. You say that the enrollee cannot take Avastin. The Plan denied your request. The Plan says that the denial of authorization for this drug is correct, because there are not enough studies showing that Alimta will improve health outcomes for the enrollee's condition.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 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 Alimta. Our reviewer says that the enrollee meets the Medicare criteria for the requested use of Alimta. Our physician reviewer found the requested use of Alimta is not Food & Drug Administration (FDA) approved for the enrollee's diagnosis. However, this use is supported by a major drug compendium. The documentation supports that the requested use of Alimta is safe and effective and otherwise reasonable and necessary 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 Alimta have been met. Therefore, we decided that the Plan has to pre-approve use of Alimta.

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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide a therapeutic continuous glucose monitor.
You asked the Plan to provide a therapeutic continuous glucose monitor. You say that because of medical
conditions you cannot finger stick test. The Plan denied your request. The Plan says criteria is not met because
you do not inject insulin three or more times a day or adjusts insulin dosage based on glucose readings.
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 and have had an in-person visit with their treating physician to assesses
adherence to their CGM regimen and diabetes treatment plan.
We looked at the file and Medicare rules. The documentation indicates that you do not perform blood glucose
testing at least four times per day, use insulin with at least three daily injections, nor require frequent selfadjustment
of insulin dosage based on the blood glucose testing results. Based on this information, we decided
that Medicare rules for coverage of a therapeutic continuous glucose monitor have not been met. Therefore, we
decided that the Plan does not have to provide a therapeutic continuous glucose monitor.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the intracept procedure (CPT code(s): 22899 and C9752), for the enrollee.
You asked the Plan to pre-approve the intracept procedure. You say that this procedure fills a treatment gap for those patients that do not receive adequate relief from traditional conservative methods and do not have instability to indicate that fusion is the appropriate treatment. You state the enrollee has tried and failed conservative treatment without relief. The Plan denied your request. The Plan says the services are considered experimental and investigational.
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 intracept procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the intracept procedure is experimental. More research is needed to show safety and efficacy of the procedure for the treatment of low back pain.
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 intracept procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the intracept procedure (CPT code(s): 22899 and C9752), for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the breast prostheses (L8000, L8030) provided February 2, 2021.
You asked the Plan to pay for the breast prostheses. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says this claim is missing required documentation.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery.
The record does not contain relevant medical records which support medical necessity for the supplies provided in this case. In this case, no medical records were provided which substantiate that the criteria for the ordered items have been met. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the breast prostheses (L8000, L8030) provided February 2, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Oxycodone HCL ER.
You asked the Plan to pre-approve Oxycodone. You say that this request is medically necessary. The Plan denied your request. The Plan says this drug is not covered under the enrollee's medical benefit.
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 Oxycodone HCL ER.
Benefits for Oxycodone 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: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Evenity.
You asked the Plan to pre-approve Evenity. You say that this request is medically necessary. The Plan denied your request. The Plan says the Plan's step therapy criteria have not been met.
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 Evenity. Our reviewer says that the requested drug is not medically reasonable and necessary. Our physician reviewer found the Plan requires a trial of Prolia or Reclast (zoledronic acid) before they will approve the requested drug. In this case, the patient has not tried and failed the required drug(s). There is no documentation provided indicating that the Plan's required drug(s) 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 Evenity have not been met. Therefore, we decided that the Plan does not have to pre-approve Evenity.
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 services are medically necessary as the enrollee cannot be adequately cared for in their current condition at a lower level of care. The enrollee requires prolonged hospitalization. The Plan denied your request. The Plan says the enrollee can receive the necessary services at the current level of care, and a transfer to an LTACH would provide no clinical advantage.

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 there is no documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 

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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient services provided from March 11, 2021, to March 13, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the outpatient claim was billed with an inpatient-only procedure.
The Plan must follow Medicare rules. Medicare rules say that there is no payment under the Outpatient Prospective Payment System (OPPS) for services that CMS designates to be "inpatient-only" services. We looked at the file and Medicare rules. In this case, the outpatient claim cannot be paid due to an inpatient-only procedure being billed on the claim. 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 outpatient services provided from March 11, 2021, to March 13, 2021.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve the FreeStyle Lite test strips.
You asked the Plan to pre-approve the FreeStyle Lite test strips. You say that these items are medically necessary for the enrollee's condition. The Plan denied your request. The Plan says that you must use the Plan's preferred glucose test strips.
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. In this case, we requested medical records from the enrollee's provider on why the Plan's preferred test strip would not be sufficient. We received no information on why medical records were not returned .Therefore, we decided that the Plan has to pre-approve the FreeStyle Lite test strips.