Persius/hicric huggingface dataset:
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 admission to a SNF. You say that the requested admission to a SNF is medically necessary.The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF admission.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve admission to a SNF. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee is with a past medical history of hypertension, diabetes, arthritis, chronic kidney disease, neuropathy and recent left shoulder surgery who presented to the acute hospital on 07/25/2020 with weakness and inability to care for herself. She was treated in the hospital and she is weak and unsteady and is working with physical and occupational therapy. She is walking with a walker with contact guard assistance and is supervision for transfers and moderate to maximum assist for activities of daily living. She is medically stable.Based on the medical records provided this enrollee does not require skilled nursing services, i.e., the specialized skill, knowledge and judgment of a skilled professional nurse required to safely and effectively provide medically necessary and reasonable treatment. Based on the medical records provided this enrollee does require skilled therapy services, i.e., the specialized skill, knowledge and judgment of a qualified therapist required to safely and effectively provide medically necessary and reasonable treatment. Based on the medical records provided daily skilled services are not required. Based on the medical records provided this enrollee does not require the services on 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 admission to a SNF 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Nplate.
You asked the Plan to pre-approve Nplate. You say that the requested Nplate is medically necessary. The Plan
denied your request. The Plan says the requested Nplate is not medically necessary.
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 Nplate. Our reviewer says that the
requested Nplate is not medically necessary. Our physician reviewer found the enrollee is with stage IV mantle
cell lymphoma. The requested use of Nplate is not FDA-approved for the enrollee's diagnosis. The use is not
supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical
journal. The use is listed as not indicated, not supported or not recommended in any of the compendia.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Nplate have not been met. Therefore, we decided that the Plan does not have to
pre-approve Nplate.
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 services are medically necessary. The
Plan denied your request. The Plan says the services are not medically necessary.
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 services are not medically necessary. Our physician reviewer found the enrollee was admitted to the
hospital on July 4, 2020 with a subdural hematoma. He was intubated for altered mental status and respiratory
distress. On July 29, 2020 he was minimally opening his eyes to voice and was agitated with stimulation. 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. The clinical assessment in the case file
does not support that the enrollee is reasonably expected to benefit from, and improve with, LTACH services.
The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and
condition of the enrollee 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 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 pre-approve bilateral facet joint injections.
You asked the Plan to pre-approve bilateral facet joint injections. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not been met.
The Plan must follow Medicare rules. 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 bilateral facet joint injections. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found in this case, the pain radiates to the right shoulder. According to the criteria, this should not be associated with radiculopathy or neurogenic claudication. The review has determined that the requested bilateral facet joint injections in this case are not medically reasonable or 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 bilateral facet joint injections have not been met. Therefore, we decided that the Plan does not have to pre-approve bilateral facet joint injections.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe wrist hand orthosis provided on December 16, 2019.You asked the Plan to pay forthe wrist hand orthosis (L3916). You say that the orthosis was medically necessary.The Plan denied your request. The Plan says they were unable to discover any evidence of an established relationship between the member and the ordering physician.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. The medical records provided show thenew patient office visit occurredafter the date of service. Based on this information, we decided that Medicare rules for coverage of the wrist hand orthosis (L3916) have not been met.Therefore, we decided that the Plan does not have to pay forthe wrist hand orthosis providedon December 16, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an x-ray of the abdomen (74018) provided October 8, 2019.
You asked the Plan to pay for the x-ray. You say that the services were medically necessary. The Plan denied your request. The Plan says Original Medicare is liable for payment for these services.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for an x-ray of the abdomen (74018) provided October 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dermatology services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve dermatology services. You say that you would like to see this provider because they are close to home. The Plan denied your request. The Plan says these services can be safely rendered with an in-network provider.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 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. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve dermatology services to be provided by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says the frequency and duration of service are not reasonable, and the enrollee can be provided therapies at a lower level of care such as three times a week.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no required skilled nursing services identified. The enrollee may benefit from skilled therapy services to maximize her independence with ADLs, but the documentation does not support that daily skilled therapy services are medically reasonable and necessary. As a practical matter, the enrollee does not require the services on 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 admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acupuncture services to be provided by an out of network (OON) provider.You asked the Plan to pre-approve acupuncture services. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says there are in-network providers available for these services.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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.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. We found no exception that would require the Plan to pre-approve these items/services.Therefore, we decided that the Plan does not have to pre-approve acupuncture services to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aralast NP.You asked the Plan to pre-approve Aralast NP. You say that the medication is necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill.In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be brought to the office for administration. Since the medication does not represent an expense to the physician and will not be included in the physician's bill, it is not eligible for Part B coverage.Therefore, we decided that the Plan does not have to pre-approve Aralast NP.Benefits for Aralast NPareavailable under the enrollee'sMedicare Part Dplan.Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on July 26, 2019.You asked the Plan to pay for the drug testing services. The Plan denied your request. The Plan says the billed code cannot be verified.The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab requisition stating exactly which testing was to be performed. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met.Therefore, we decided that the Plan does not have to pay for the drug testing services provided on July 26, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for emergency room services (99285, 93010) provided January 1, 2020.
You asked the Plan to pay for the emergency room services. You say that the services should be covered. The Plan denied your request. The Plan says Original Medicare is liable for payment for services until the first day of the month after the hospice election has been revoked or terminated.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. The enrollee ended Medicare Hospice benefits on January 1, 2020. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for emergency room services (99285, 93010) provided January 1, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power mobility device.
You asked the Plan to pre-approve a power mobility device. You say that you need a power mobility device.
The Plan denied your request. The Plan says the record shows you have normal upper extremity strength and
are able to use a manual wheelchair.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not
have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.
The file shows your condition can be improved by a manual wheelchair. There is no home assessment. The
medical notes state you do not need assistance with MRADLs or walking. This means that Medicare rules for
coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a
power mobility device.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveProcrit.You asked the Plan to pre-approvethese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the step therapy requirement is not 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has stage III non-small cell lung cancer (NSCLC) with chemotherapy-induced anemia. She has not tried and failed the Plan's required drug of Retacrit. The records do not support that the required drug would be less effective or contraindicated; therefore, Procrit is not reasonable or medically necessary.We looked at this physician's review, thefile, 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-approveProcrit.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve stem cell therapy.You asked the Plan to pre-approve stem cell therapy. You say that you need this because you cannot have surgery.The Plan denied your request. The Plan says this is experimental.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 stem cell therapy. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found stem cell therapy remains experimental for the treatment of knee disorders. More research is needed to show that it is safe and effective.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of stem cell therapy have not been met.Therefore, we decided that the Plan does not have to pre-approve stem cell therapy.
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 requested IRF admission is medically necessary.
The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.
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
enrollee does not meet criteria for IRF admission. Our physician reviewer found the enrollee is with history of
fibromyalgia and lumbar laminectomy, admitted and now status post thoracic decompression surgery. The
post-operative course has included management of pain, and mobility limitations. The enrollee is now nontoxic
and afebrile. Labs and vitals are stable. She is mostly minimal assist for care currently.
Records do not indicate that there are significant, or complex medical/nursing issues that could not be
addressed at a lesser level of care. Ongoing pain medication and other medication management, wound care,
and daily therapy can be provided at a lesser level of care. In this case, the member is mostly minimum assist
for functional transfers and activities of daily living and a less intensive, longer duration of therapy will allow
for measurable gains to be attained within a reasonable, and predicted period. An IRF intensity is not
warranted.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis and suspension sleeve provided on January 21, 2020.
You asked the Plan to pay for the knee orthosis (L1833) and suspension sleeve (L2397). You say that the orthosis was medically necessary. The Plan denied your request. The Plan says 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. The rules state that DMEPOS is covered only when there is a physician order, proof of delivery, and documentation supporting medical necessity. The medical records do not mention or support medical necessity for the orthosis. Therefore, we decided that the Plan does not have to pay for the knee orthosis and suspension sleeve provided on January 21, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued admission to a skilled nursing facility (SNF)
for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your
request. The Plan says the enrollee is at baseline level of function, with no nursing services need, and not
requiring ongoing daily services at the SNF level of care.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed above are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found no required skilled services beyond
7/24/20 are identified. No daily skilled therapy is needed. As a practical matter, the services are not required on
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 services have not been met. Therefore, we decided that the Plan does not
have to pre-approve continued admission to a skilled nursing facility (SNF) for the enrollee.