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

We decided that the Plan has to pre-approveplacement of a CardioMEMS heart failure monitor.You asked the Plan to pre-approvethe CardioMEMS device. You saythat this device is needed in order to reduce hospital stays for this enrollee.The Plan denied your request. The Plan says that the evidence of the clinical efficacy of this procedure is not sufficient to warrant coverage.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 thecase file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the CardioMEMSdevice. Our reviewer says that the requested services are considered medically reasonable and necessary in this case.Our physician reviewer found the patient has a severe ischemic cardiomyopathy complicated by renal insufficiency and difficulty in titrating diuretics to maintain both euvolemia and renal function. She is on a complex medical regimen and is having some difficulty following the many adjustments to the multiple medications she uses. She was recently hospitalized with CHF and presents back to the office with significant volume overload again necessitating adjustments of her medications and aggressive diuresis. There is reasonable published data that monitoring with CardioMEMSdevice in this clinical situation can improve symptoms and decrease repeat hospitalizations for CHF. Particularly, in this instance the patient has a severe ischemic cardiomyopathy, is on a complex medical regimen and her CHF has not been well controlled with current management. She had been hospitalized recently and presents now with hypovolemia and CHF to the office. Her diuretic and medical therapy changes regularly and she also has renal insufficiency making management of fluid status even more difficult. Given the severe symptoms of recurrent CHF which appears very sensitive to volume loading conditions, complexity of the medical regimen and the failure to prevent acute CHF hospitalization in this patient, use of the CardioMEMSdevice is reasonable and has both clinical data and expert opinion to back up its use in selected appropriate clinical situations.We looked at this physician's review, the file, and Medicare rules. Based onthis information, we decided that Medicare rules for coverage of the CardioMEMSdevice have been met.Therefore, we decided that the Plan has to pre-approveplacement of a CardioMEMS heart failure monitor.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-approveposaconazole DR 100mg tablets.You asked the Plan to pre-approvethe posaconazole tablets. You say thatthis drug is medically necessary.The Plan denied your request. The Plan says this oral drug is not covered by Medicare Part B.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pre-approveposaconazole DR 100mg tablets.Benefits for the posaconazole tabletsmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a stair lift.
You asked the Plan to pre-approve a stair lift. You say that you need this because of your diagnosis of multiple sclerosis. The Plan denied your request. The Plan says that this is not a covered item.
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they are not primarily medical in nature. While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a stair lift.
Appeal type: ER
Decision: Favorable

We decided that the Plan has to pay for an electrocardiogram (93010) provided on September 22, 2019.You asked the Plan to pay for the electrocardiogram. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says that payment is not allowed for this service because it was billed with a missing or inappropriate modifier.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 todeny your request. The Plan did not forward sufficient medical records to verify the initial service rendered. It is the burden of the Medicare Health Plan to substantiate the denial with evidence. Additional medical records are necessary from the initialprovider in this case, to determine if the modifiers billed are appropriate or not. Without the additional medical records, the denial is not substantiated and we must find in your favor.Therefore, we decided that the Plan has to pay for an electrocardiogram (93010) provided on September 22, 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 usthe 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 pay for anesthesia services provided on March 20, 2019.You asked the Plan to pay for the anesthesia services. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.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 Plandid not pre-approve the servicesat issue. We found no exception that would require the Plan to pay for these services. Therefore, we decidedthat the Plan does not have to pay for anesthesia services provided on March 20, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.
You asked the Plan to pay for the ambulance services. You say that you have braces on both of your legs and
do not have any support to get yourself up in the event of a fall. You say that you when you did fall, you called
911 and explained that you only needed help getting back into your wheelchair and not an ambulance. You
stated that you were told by the ambulance driver that day that you would owe nothing. The Plan denied your
request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when
there is no transport.
The ambulance company did not provide transport services on September 17, 2019. The ambulance benefit is a
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.
Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve an myoelectric prosthesis with accessories
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan denied your request. The Plan says that the services are 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 these services. Our reviewer says that the services are medically necessary. Our physician reviewer found the enrollee has bilateral shoulder osteoarthritis and has failed the use of a body-powered prosthesis. The shoulder osteoarthritis would be expected to limit her ability to use a body product powered prosthesis. A myoelectric prosthesis is considered the standard of care for her condition. It is reasonable and medically necessary for her to have a myoelectric prosthesis with the requested accessories, as she has already failed the use of a standard body-powered prosthesis. 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 been met. Therefore, we decided that the Plan has to pre-approve an myoelectric prosthesis with accessories
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the requested admission to an IRF is medically necessary.The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.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 admission to an IRF does not meet criteria. Our physician reviewer found the enrollee was hospitalized for generalized weakness and myalgia, and head imaging was negative for acute hemorrhage or recent ischemia. Head imaging showed chronic left infarct. The enrollee had elevated blood glucose and blood pressure on admit. Pain management consulted due to chronic pain. MRI of the left shoulder on 2/27 revealed non-displaced acromion fracture and partial tear of long head of biceps and anterior infraspinatus and supraspinatus. He had an acute flare of rheumatoid arthritis with elevated titers. Prior to admit the enrollee was independent for gait and activities of daily living. The enrollee's current level of function on 3/2 was needing supervision or set up to minimal assistance with dressing and toileting, and ambulating 200 feet with rolling walker. In occupational therapy the enrollee needed minimal assistance for upper body dressing, supervision for lower body dressing, and minimal assist for toileting. On 3/2/20 pain was better, no new complaints. Blood glucose 133. Vital signs stable. The complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that the enrollee's medical status requires the intensity of an IRF stay with close physician or nursing supervision. The enrollee may benefit and participate in additional therapy of physical therapy and occupational therapy but the enrollee's functional status does not require this on an intensive rehabilitation facility therapy program level 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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvebone marrow aspiration (20939).You asked the Plan to pre-approvebone marrow aspiration (20939). You say that the requested bone marrow aspiration is medically necessary.The Plan denied your request. The Plan says the requested bone marrow aspiration 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 bone marrow aspiration (20939). Our reviewer says that the requested bone marrow aspiration is not medically necessary. Our physician reviewer found this enrollee is status post L3-S1 lumbar fusion andis indicated for removal of L3/4 hardware and extension of the fusion to the L2/3 level with transforaminal lumbar interbody fusion. Under consideration is a request for bone marrow aspirate. There is no specific indication provided to support the requestfor bone marrow aspirate for the approved surgery. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of bone marrow aspiration in conjunction with the planned lumbar surgery. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of bone marrow aspirate for this enrollee's medical condition as discussed above. Therefore, the request for bone marrow aspirate is not medically reasonable and necessary for the approved lumbar fusion.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of bone marrow aspiration (20939) have not been met.Therefore, we decided that the Plan doesnot have to pre-approvebone marrow aspiration (20939).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveadmission to a skilled nursing facility (SNF).You asked the Plan to pre-approveadmission to a skilled nursing facility (SNF). You say that the requested admission to a SNF is medically necessary.The Plan denied your request. The Plan says the requested admission to a SNF does not meet criteria.The Plan must follow Medicare rules. The rules say thatMedicare 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 admission to a skilled nursing facility (SNF). Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to acute care on 02/27/2020 for a planned hardware removal of right hip followed by a right total hip arthroplasty for the treatment of avascular necrosis of the right femoral head. The provided medical records were reviewed. Her operative procedure and hospital course were without complications. She did requirea post-operative blood transfusion of 2 units of packed red blood cells. Her hematocrit after this was 35.5%. She did have intermittent tachycardia and low blood pressure during the hospitalization but records indicate that these were asymptomatic. By thetime of discharge on 03/03/2020 she was medically stable, on no intravenous medications and her surgical wound was clean and dry with no signs of infection. Her pain was controlled with Tylenol and oxycodone. She was walking with a front wheeled walker upto 100 feet and requiring minimal assistance with transfers. She was on a regular diet and weight bearing as tolerated. Skilled nursing and therapy services in a skilled nursing facility were requested. The provided medical records do not indicate a need for skilled nursing services. The provided medical records do indicate a need for skilled therapy services. The provided medical records do not indicate a need for daily skilled services. The provided medical records do not indicate a need for inpatient services. The requested admission to a SNF is not medically necessary at this 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 admission to a skilled nursing facility (SNF) have not been met.Therefore, we decided that the Plan does not have to pre-approveadmission to a skilled nursing facility (SNF).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forthe skilled nursing services provided on November 5, 2019 by an out ofnetwork (OON) provider.You asked the Plan to pay forthe skilled nursing. You say that the medical records provided support the necessity of the services in dispute.The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider. The plan says that non-emergent services with non-contracted providers require prior-authorization prior to services being rendered.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 withthe 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 forthe skilled nursing services provided on November 5, 2019 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for CPT code 32555 provided on March 12, 2019.You asked the Plan to pay for CPT code 32555. You say that the medical records support the billing of CPT code 32555.The Plan denied your request. The Plan says the medical records do not support the billing of CPT code 32555.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 32555 is Thoracentesis, needle or catheter, aspiration of the pleural space; with imaging guidance.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 CPT code 32555. Our reviewer says that the medical records do not support the billing of CPT code 32555. Our physician reviewer found CPT code 32555, Thoracentesis, needle or catheter, aspiration of the pleural space; with imaging guidance does not appear to be the correct code for the thoracentesis performed on 3/12/2019. There is no documentation in the medical record that imaging was used during the thoracentesis.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CPT code 32555 have not been met.Therefore, we decided that the Plan does not have to pay for CPT code 32555 provided on March 12, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services provided on July 5, 2019 by an out of network provider. You asked the Plan to pay forthe ambulance services. You say that the ambulance service was medically necessary.The Plan denied your request. The Plan says you did not request prior authorization.Medicare rules saythat 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 forthe ambulance services provided on July 5, 2019 by an out of network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveProlia.You asked the Plan to pre-approveProlia. You say that Prolia is medically necessary.The Plan denied your request. The Plan says a trial of plan preferred drug Reclast is required before alternatives can be considered.Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicatesthat 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 Prolia. Our reviewer says that coverage criteria has not been met. Our physician reviewer found the enrollee has osteopenia, not osteoporosis.  A bone density scan has not been submitted for review.  There is no evidence that the enrollee is taking an aromataseinhibitor.  As such, the Prolia is not indicated.  Additionally, there is no evidence that the enrollee has tried Reclast.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have not been met.Therefore, we decided that the Plan does not have to pre-approveProlia.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve Precision Q-I-D test strips.
You asked the Plan to pre-approve Precision Q-I-D test strips. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says that the requested items are not covered.
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. Specifically, it is the plan's responsibility to show that its decision to deny coverage is correct. Records from a plan provider are considered to be within the control of the plan. In cases where the plan has not supplied records from a plan provider that are critical to its decision, we may properly find that the denial is not medically appropriate or justifiable. Enrollees should not be penalized for a plan's failure to obtain records that are within the plan's control. Therefore, we decided that the Plan has to pre-approve Precision Q-I-D test strips.