Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation of the sacral lateral branches.

You asked the Plan to pre-approve the radiofrequency ablation of the sacral lateral branches. You say that the
treatment of the enrollee's pain with sacral lateral branch radiofrequency ablation is appropriate and medically
necessary for her. The Plan denied your request. The Plan says the records provided do not show that the
services in dispute are reasonable and necessary for the enrollee's condition.

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 radiofrequency ablation of the
sacral lateral branches. Our reviewer says that the criteria for coverage have not been met. Our physician
reviewer found this is considered experimental and investigational because of the wide variation in efficacy in
the peer reviewed literature. Therefore, the request is considered 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 the radiofrequency ablation of the sacral lateral branches have not been met.
Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation of the sacral lateral
branches.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.

You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. The Plan denied your request. The Plan says that records show the enrollee's condition continues to worsen, and a team of different experts have not evaluated the enrollee to see if another level of care would be more appropriate.

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. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH services. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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 for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission and services.

You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says your needs are primarily custodial at this time.

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 SNF services. Our physician reviewer found that you are at a minimal assist level for bed mobility, contact guard assist for transfers, and contact guard assist for ambulation with a two-wheeled walker. The documentation does not support that the skilled nursing services of a skilled professional nurse is required to provide medically necessary treatment. You do not have complex wound care or other skilled nursing needs that requires a SNF stay. Your functional level does not require the skilled therapy services of a qualified therapist to provide medically necessary treatment only in a SNF. Skilled services are not needed on a daily basis or as practical matter in a SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that intensive rehab therapy is needed to maximize function and independence. The Plan denied your request. The Plan says the enrollee is unable to tolerate an intensive rehab therapy program.

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 physician reviewer found that the enrollee was admitted to the acute hospital for Covid-19. He was then discharged to skilled nursing facility where he is receiving physical and occupational therapy. His medical conditions are stable. There are no medical needs requiring inpatient admission. There are no complex nursing needs. There is not a reasonable expectation that he will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. 

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: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care provided on October 3, 2019.

You asked the Plan to pay for the physician service. You say that the medically necessary service was rendered to the enrollee in good faith. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says that it is the provider's responsibility to verify the enrollee's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.

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 date of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the subsequent nursing facility care provided on October 3, 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 you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested admission is 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 requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee was admitted to the current acute care hospital with COVID-19 and Klebsiella pneumonia and respiratory failure and was treated with oxygen and antibiotics and placed on aspiration precautions. The documentation does not support that the enrollee requires services at the LTACH that are not available at the acute care hospital where the enrollee is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. 

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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve diagnostic or therapeutic agent, paravertebral facet injection(s) (64492, 64491, 64490).

You asked the Plan to pre-approve diagnostic or therapeutic agent, paravertebral facet injection(s). 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 follows Medicare rules. Medicare rules say that Facet Joint Interventions are considered medically reasonable and necessary when specific criteria is 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 diagnostic or therapeutic agent, paravertebral facet injection(s). Our reviewer says that the services are not medically necessary. Our physician reviewer found there is no documentation of physical exam limitations, trials of NSAIDs and of other conservative therapies. The request does not meet the criteria. Therefore, at this time, the request is considered 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 diagnostic or therapeutic agent, paravertebral facet injection(s) have not been met. Therefore, we decided that the Plan does not have to pre-approve diagnostic or therapeutic agent, paravertebral facet injection(s) (64492, 64491, 64490).
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 for the enrollee.

You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee's ongoing skilled therapy and nursing needs can be provided at home with home health care, or in a long-term care setting.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described 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. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for a fall, respiratory failure and COVID 19 pneumonia. The enrollee's medical conditions are stable. There are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. The patient 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 patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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 for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the neuromuscular stimulator (E0745).

You asked the Plan to pre-approve the neuromuscular stimulator. You say that this service is medically necessary. The Plan denied your request. The Plan says this is not a covered service for your medical condition.

The Plan must follow Medicare rules. Medicare rules say that neuromuscular stimulators are only covered when used for the treatment of muscle atrophy or used for walking in patients with spinal cord injury. 

We looked at the file and Medicare rules. The file indicates that this service is being prescribed for a medical condition other than muscle atrophy or walking in patients with spinal cord injury. Based on this information, we decided that Medicare rules for coverage of the neuromuscular stimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve the neuromuscular stimulator (E0745).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF 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 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs at this point are custodial and, as a practical matter, can be provided 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care provided on September 2, 2020, through September 25, 2020.

You asked the Plan to pre-approve SNF care. You say that the service was medically necessary. The Plan denied your request. The Plan says the service was not medically necessary.

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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee's care needs at this point were custodial and, as a practical matter, could be provided 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 SNF care have not been met. Specifically, the services could have been obtained at a lower level of care. This means the SNF care is not reasonable or necessary. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care provided on September 2, 2020, through September 25, 2020.
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 admission to an IRF 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 complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for cervical spine surgery to treat spinal stenosis. She was discharged to a skilled nursing facility where she is receiving physical and occupational therapy services. Medical conditions are stable. There are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. 

The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, in 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. 

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: Lab
Decision: Favorable

We decided that the Plan has to pay for the presumptive and definitive drug testing provided on June 4, 2020.

You asked the Plan to pay for the drug testing. You say that the records support the need for this testing. The
Plan denied your request. The Plan says that the file does not include a valid order signed by the treating
physician for this testing.

The Plan must follow Medicare rules. Medicare rules say that lab testing may be covered when ordered by the
treating provider. Orders need not be signed but the intent must be clearly documented in the record.

In this case, while the order forms themselves were not signed by the treating provider, the progress note
clearly indicates the intent to provide this testing. There are also multiple other documents in the file which
support that this testing was ordered by the treating physician. Therefore, we decided that the Plan has to pay
for the presumptive and definitive drug testing provided on June 4, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a breast prosthesis, mastectomy sleeve (L8010).

You asked the Plan to pre-approve this item. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says this item is not a covered benefit under your contractual policy or by Medicare.

The Plan must follow Medicare rules. Medicare rules say that a mastectomy sleeve coded as L8010 is denied as non-covered since it does not meet the definition of a prosthesis. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this item have not been met. Specifically, a mastectomy sleeve coded as L8010 is considered to be non-covered by Medicare as it does not meet the definition of a prosthesis. Therefore, we decided that the Plan does not have to pre-approve a breast prosthesis, mastectomy sleeve (L8010).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide a therapeutic continuous glucose monitor.

You asked the Plan to provide a therapeutic continuous glucose monitor. You say that the enrollee needs a
CGM. The Plan denied your request. The Plan says criteria is not met for a CGM.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based
on the blood glucose testing results.

We looked at the file and Medicare rules. The documentation does not show the enrollee performs blood
glucose testing at least four times per day and indicates the enrollee does not use insulin with at least three
daily injections. Based on this information, we decided that Medicare rules for coverage of a therapeutic
continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to provide a
therapeutic continuous glucose monitor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the continuous glucose monitoring (CGM) systems
(K0553).

You asked the Plan to pre-approve the CGM systems. You say that this service is necessary. The Plan denied
your request. The Plan says you do not meet criteria for coverage for CGM.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based
on the blood glucose testing results.

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin
with at least three daily injection. Based on this information, we decided that Medicare rules for coverage of
the CGM systems have not been met. Therefore, we decided that the Plan does not have to pre-approve the
continuous glucose monitoring (CGM) systems (K0553).