Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve therapeutic massage for the enrollee.

You asked the Plan to pre-approve the therapy. You say that this is medically necessary. The Plan denied your
request. The Plan says massage is not covered as an isolated treatment.

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient
therapy.

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 therapy. Our reviewer says that
skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's
condition. Our physician reviewer found the enrollee has had prior massage therapy for his condition and the
documentation does not indicate that the enrollee has objective deficits or that his functional level requires the
ongoing unique skills of a professional massage therapist to safely and effectively provide treatment, or that the
services can be safely and effectively performed only by a therapist, or under the supervision of a therapist. The
enrollee is not getting PT or OT. The documentation does not reveal objective physical exam progress notes
from the enrollee's treating medical practitioner with findings that indicate the additional requested services are
medically necessary. There is no indication that massage is being performed as an adjunct to another medically
necessary treatment.

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 therapy have not been met. Therefore, we decided that the Plan does not
have to pre-approve therapeutic massage 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 disagree with the denial. The Plan denied your
request. The Plan says the services are 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 medically necessary. Our physician reviewer found the enrollee was admitted to the
hospital for surgical repair of a hip fracture after a fall. His medical conditions are stable. There are no medical
needs requiring an inpatient admission, complex nursing, or rehabilitation needs. The enrollee does not require
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive
rehabilitation therapy program. While the medical record documents a need for physical and occupational
therapy, it does not document a need for an intensive rehabilitation program. There is not a reasonable
expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation
therapy program provided in an IRF.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: 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 all your doctors are recommending IRF placement.
The Plan denied your request. The Plan says the services are 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 medically necessary. Our physician reviewer found the submitted records show that
you were admitted to the hospital on February 10, 2021, for planned heart surgery. The physical therapy note
on February 24, 2021, states you need assistance with transfers and bed mobility. You are walking 200 feet
with a walker and assistance. The complexity of your nursing, medical and rehabilitation needs does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your medical
status does not require intensive physician or nursing supervision in an IRF. While you may benefit from
further therapy, you do not require an intensive therapy program in an IRF.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for specialist visits provided on August 24,
2020, and September 11, 2020.

You asked the Plan to waive the copayments for specialist visits. You say that you disagree with the charges
because you got a second opinion and saved the Plan thousands of dollars. The Plan denied your request. The
Plan says the claims were processed correctly, and you are being charged the correct amount.

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 $25
copayment for specialist visits.

You received specialist visits on August 24, 2020, and September 11, 2020. Therefore, you are responsible to
pay a $25 copayment per each visit. The total amount you owe is: $50.

You have been asked to pay the total copayment amount of $50 for specialist visits. Specialist visits fall within
the physician/practitioner services, including doctor's office visits 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 copayments for specialist visits provided on August 24, 2020, and September 11, 2020.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for shipping for a CPAP machine and supplies received on August 18, 2020.

You asked the Plan to pay for the shipping. You say that you would like to be reimbursed. The Plan denied your request. The Plan says that this is not covered by Medicare.

Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules. 

You were referred for a CPAP machine and supplies by your PCP, a contract provider. The file does not show that the Plan provided notice that the services would not be covered. You would have no way of knowing that the plan would not cover the shipping for an otherwise covered device. Under Medicare rules, this means the shipping is considered approved by the Plan. Therefore, we decided that the Plan has to pay for shipping for a CPAP machine and supplies received on August 18, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve an epidural steroid injection (ESI).

You asked the Plan to pre-approve these services. You say that you disagree with the denial. 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 submitted records show that you have chronic neck and right arm pain. You have had physical therapy (PT) in the past and are currently receiving PT two times per week. You are taking diclofenac, Tylenol, and ibuprofen for the pain. You had a prior cervical ESI in January of 2021 that provided 80 percent pain relief for two weeks. The repeat injection is reasonable and 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 these services have been met. Therefore, we decided that the Plan has to pre-approve an epidural steroid injection (ESI).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the new patient domiciliary, rest home visit (99326 provided
on February 18, 2020, by an out-of-network (OON) provider.

You asked the Plan to pay for the domiciliary, rest home visit. You say that please reconsider this claim. The
Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network
provider with the exception being urgent or emergent services. Non-emergent services with non-contracted
providers require prior authorization before 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 with the Plan. The Plan had network providers
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for the new patient domiciliary, rest home visit
(99326 provided on February 18, 2020, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a walker that is enclosed on four sides (E0144).

You asked the Plan to pre-approve the special walker. You say that this type of walker is necessary. The Plan denied your request. The Plan says the enclosed frame walker is not necessary.

The Plan must follow Medicare rules. Medicare rules say that the necessity for a walker with an enclosed frame has not been established. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the special walker have not been met. Therefore, we decided that the Plan does not have to pre-approve a walker that is enclosed on four sides (E0144).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gelsyn-3 (J7328).

You asked the Plan to pre-approve Gelsyn-3 (J7328). You say that you want the enrollee treated with this drug. The Plan denied your request. The Plan says the enrollee has not first tried and had a contraindication or intolerance to Orthovisc and Monovisc.

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 Gelsyn-3 (J7328). Our reviewer says that the drug is not medically necessary. Our physician reviewer found 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 Gelsyn-3 (J7328) have not been met. Therefore, we decided that the Plan does not have to pre-approve Gelsyn-3 (J7328).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Brovana (J7605).

You asked the Plan to pre-approve Brovana. You say that the exception is needed. The Plan denied your request. The Plan says Part B medications do not qualify for tier exceptions.

The Plan must follow Medicare rules. Medicare rules say that tiered cost-sharing means a process of grouping Part D drugs into different cost sharing levels within a Part D sponsor's formulary. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Brovana have not been met. Therefore, we decided that the Plan does not have to pre-approve Brovana (J7605).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says you do not meet the criteria for coverage.

The Plan must follow Medicare rules. Medicare rules say that a therapeutic CGM is covered when specific criteria are met. 

We looked at the file and Medicare rules. The file shows that you are not treated with insulin. 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 a continuous glucose monitor (CGM).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy.

You asked the Plan to pre-approve these services. You say that you are unable to use your arm and need PT to continue to care for yourself. The Plan denied your request. The Plan says the services are not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 

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 skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the records show that you have had extensive therapy for your condition. The documentation does not indicate that your functional level requires the unique skills of a professional therapist to safely and effectively provide treatment. The additional therapy is not generally accepted as specific and effective therapy for your condition. You have been given a home exercise program. The services are not part of a maintenance program. You do not require the specialized skill, knowledge and judgment of a qualified therapist to establish, design and/or deliver a program to maintain your current condition or to prevent or slow further deterioration. 

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 physical therapy.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xgeva.

You asked the Plan to pre-approve Xgeva. You say that this is medically necessary. The Plan denied your request. The Plan says that you have not tried and failed the step therapy drugs.

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 Xgeva. Our reviewer says that Xgeva is not medically reasonable and necessary. You have not tried and failed pamidronate or zoledronic acid. There is no documentation provided indicating that pamidronate or zoledronic acid would likely be less effective and/or likely have adverse effects for you. Our physician reviewer found that your condition does not meet step therapy criteria for Xgeva. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Xgeva have not been met. Therefore, we decided that the Plan does not have to pre-approve Xgeva.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 11, 2020 by an out of network (OON) provider.

You asked the Plan to pay for detoxification visit. You say that there was no time to submit a prior authorization request as this happened overnight, and you were under the impression the Plan would cover this treatment. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and authorization was not obtained.

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 had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the medical services provided on August 11, 2020 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion services (S9328) July 16, 2020 to September 24, 2020.

You asked the Plan to pay for the home infusion services. You say that the services were medically necessary. The Plan denied your request. The Plan says the billed code is not eligible for Medicare payment.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

We find that CPT code S9328 is not supported in the medical record. Specifically, per the National Physician Fee Schedule, code S9328 is listed with a status "I" and is invalid for Medicare payment. Based on this information, we decided that Medicare rules for coverage of the home infusion services have not been met. Therefore, we decided that the Plan does not have to pay for home infusion services (S9328) July 16, 2020 to September 24, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient hospital care.

You asked the Plan to pre-approve acute inpatient hospital care. You say that the services are 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. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 

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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient admission. Our physician reviewer found there is no specific clinical rationale for the requested inpatient admission. The planned procedure listed under CPT code 23472 is not listed on the CMS Inpatient Only List. The arthroplasty procedure is currently approved as an ambulatory outpatient procedure. There is no documentation provided to support the expectation the enrollee will require a greater than 2 midnight stay. If the enrollee experiences any peri- or post-operative complications, reconsideration for inpatient level of care can be performed on concurrent review with updated clinical information. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Rabeprazole for the enrollee.

You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your request. The Plan says that this is not covered under 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-approve Rabeprazole for the enrollee.

Benefits for this drug 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a segmental pneumatic compression device for the enrollee.

You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says there must be a trial of conservative therapy documented in the medical records.

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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not support that the enrollee has objective physical exam findings of lymphedema of the chest, trunk, or abdomen. There is no evidence of unique characteristics that would indicate the segmented pump over a standard pump. There is no documentation of a trial and failure of the standard pump.

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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve a segmental pneumatic compression device for the enrollee.