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

We decided that the Plan does not have to pre-approve a Vertiflex Interspinous Spacer.
You asked the Plan to pre-approve a Vertiflex Interspinous Spacer. The Plan denied your request. The Plan says this is not medically necessary.
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 a Vertiflex Interspinous Spacer. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that this enrollee presents with complaints of chronic bilateral radicular low back pain. Signs/symptoms are reported consistent with intermittent neurogenic claudication. Current evidence based medical guideline and peer reviewed literature do not fully support the spinal decompression device procedure over the 'gold standard' of lumbar laminectomy. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of this device for this enrollee's medical condition as discussed above. FDA indications have not been met as there are no documented imaging findings of moderate spinal stenosis. Additionally, FDA contraindications include osteoporosis. There is documentation of multiple thoracolumbar compression fractures and prior treatment of osteoporosis with no documentation of current bone mineral density scores. Therefore, this request for the Vertiflex interspinous spacer procedure would not be considered medically reasonable and 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 a Vertiflex Interspinous Spacer have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex Interspinous Spacer.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Repatha Sure Injections.
You asked the Plan to pre-approve the Repatha Sure Injections. You say that the enrollee has hyperlipidemia and that the requested drug is medically reasonable and necessary. The Plan denied your request. The Plan says this medication falls under Part D coverage, but the enrollee has no Part D pharmacy benefit through the Plan.
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 Repatha Sure Injections.
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 records provided support the need for IRF care. The Plan denied your request. The Plan says there is no indication that the enrollee can tolerate 3 hours of therapy a day for 5 days a week. The plan says that the enrollee's current level of function is described as limited ability to walk and requiring assistance for transfers. The plan says that the medical records do not support that IRF care is medically necessary. The plan says that the enrollee's care can be provided at a skilled nursing facility.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee does not require the intensity of services provided at an IRF. Our physician reviewer found that the enrollee is not shown to require, or to be able to perform, fifteen hours per week of rehabilitative services with regular physician evaluation. Our physician reviewer found that 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Orencia Clickject
You asked the Plan to pre-approve the Orencia Clickject. You say that the enrollee has tried multiple medications and this is the only medication that is working. You say that you would like to continue use of this medication. The Plan denied your request. The Plan says Orencia Clickjet falls under Part D coverage, and the enrollee has no Part D pharmacy benefit through the Plan.
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 Orencia Clickject
Benefits for the Orencia Clickject 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on July 16, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the enrollee's plan does not include out-of-network coverage.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on July 16, 2019.
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 clinical information provided supports the need for IRF care. The Plan denied your request. The Plan says IRF care 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 the records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a skilled nursing facility (SNF) level of care. Our physician reviewer found that ongoing pain medication and other medication management, skin care, and daily therapy can be provided at a SNF. Our physician reviewer found that the member is mostly minimal assist for functional transfers and activities of daily living. Our physician reviewer found that a less intensive, longer duration of therapy can allow for measurable gains to be attained within a predicted period. 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

You asked the Plan to pre-approve IRF care. You say that the enrollee is at severe risk for further damage and injury without IRF care. You say that the enrollee needs to regain his strength and mobility in order to function alone in his daily routine. The Plan denied your request. The Plan says IRF care is not medically necessary because the records show that the enrollee does not have a complex medical situation requiring multiple visits from multiple specialties and/or an intensive team approach to care.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee does not require the intensity of services provided at an IRF. Our physician reviewer found that the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. Our physician reviewer found that 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the ophthalmology services provided on August 12, 2019.
You asked the Plan to pay for the ophthalmology services. You say that you would like the plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network care.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the ophthalmology services provided on August 12, 2019.
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 clinical information provided supports the need for IRF care. The Plan denied your request. The Plan says the enrollees needs can be met in a lower level of care with a less intensive setting. The plan says that the enrollee does not meet the guidelines for coverage of IRF care, as the clinical information shows that the enrollee's needs can be safely met in a skilled nursing facility.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee does not require the intensity of services provided at an IRF. Our physician reviewer found that the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. Our physician reviewer found that the enrollee is independently mobile. Our physician reviewer found that 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided on June 12, 2019 to July 19, 2019.
You asked the Plan to pay for the physician services. You say that you would like the plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the physician services provided on June 12, 2019 to July 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the injections you received on September 19, 2019.
You asked the Plan to waive the copayment. The Plan denied your request. The Plan says you are responsible for the copayment.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 copayment for outpatient surgery services provided at an outpatient hospital. Review of the file shows that you received injections on September 19, 2019. You have been asked to pay a $250 copayment for the injections. The injections fall within the outpatient surgery benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the injections you received on September 19, 2019.
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 and that the enrollee is not clinically stable for transfer to a skilled nursing facility. The Plan denied your request. The Plan says the enrollee is currently at the appropriate level of care.
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 ongoing care needs include oxygen supplementation, surveillance laboratory studies, intravenous antibiotics, total parenteral nutrition, fluid balance, and therapy services. Our physician reviewer found that the documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving 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 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: Testing
Decision: Favorable

We decided that the Plan has to pre-approve an arterial study (CPT 93922).
You asked the Plan to pre-approve the arterial study. The Plan denied your request. The Plan says that this is not medically necessary.
The Plan follows Medicare rules. Medicare rules say that vascular studies are considered medically necessary when the above conditions are met. 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 arterial study. Our reviewer says that the requested arterial study is medically reasonable and necessary. Our physician reviewer found that the enrollee underwent a screening arterial Doppler study that was clearly abnormal in the right leg with non-compressible vessels. The enrollee has a history of peripheral vascular disease and multiple cardiovascular risk factors. He has a history of atrial fibrillation which could result in chronic embolization to the feet as well. Based on the above, there is ample evidence that a formal lower extremity arterial Doppler study is 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 the arterial study have been met. Therefore, we decided that the Plan has to pre-approve an arterial study (CPT 93922).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the clinical documentation provided supports the need for LTACH care. The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient acute care and does not require transfer to an LTACH.
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 was admitted to the acute care hospital on December 2, 2019 with right flank/lower back pain, anemia and renal failure. Our physician reviewer found that the enrollee's past medical history is notable for hypertension, CHF, COPD, arthritis, chronic kidney disease, and anemia. Our physician reviewer found that the hospital course has been complicated by respiratory failure, pneumonia, pulmonary embolism, pleural effusion, and occult GI bleeding. Our physician reviewer found that the enrollee has been weaned off BiPAP and oxygen. Our physician reviewer found that the enrollee previously lived in an assisted living facility. Our physician reviewer found that physical therapy recommended a skilled nursing facility as the next level of care. Our physician reviewer found that the enrollee is receiving acute hospital care, and acute care services have not been denied. Our physician reviewer found that the documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where she is currently receiving 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 the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided on July 18, 2019.
You asked the Plan to pay for the physician services. You say that you would like the plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network care.
The plan follows Medicare rules. Medicare rules say that for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must confirm that Medicare coverage criteria have been met. In order to determine medical necessity that pertains directly to the enrollee and their specific clinical scenario, medical records are required. In this case, there were no medical records provided for date of service June 18, 2019 confirming that the services were billed correctly. The information submitted does not confirm that Medicare coverage criteria have been met. Therefore, we decided that the Plan does not have to pay for the physician services provided on July 18, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for CPT code 95937 provided on June 5, 2019.
You asked the Plan to pay for CPT code 95937. You say that you would like the plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 95937 is Neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method. We find that CPT code 95937 is not supported in the medical record. Specifically, CPT code 95937 is not supported for train of four testing. According to CPT rules, train of four is included in other intraoperative neuromonitoring procedures and is not reported separately. Based on this information, we decided that Medicare rules for coverage of CPT code 95937 have not been met. Therefore, we decided that the Plan does not have to pay for CPT code 95937 provided on June 5, 2019.