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

We decided that the Plan has to pre-approvea Wireless Capsule Endoscopy (WCE) (91110).You asked the Plan to pre-approvea WCE. You say that the enrollee is still losing blood.The Plan denied your request. The Plan says that the source of the enrollee's bleeding was found in the colonoscopy.The Plan follows Medicare rules. Medicare rules say that WCE is indicated for the diagnosis of occult gastrointestinal bleeding, the site of which has not previously been identified by any of the tests listed 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 a WCE. Our reviewer says that the requested WCE is medically necessary. Our physician reviewer found the enrollee previously underwent a colonoscopy. This study demonstrated extensive sigmoid diverticulosis and cecal arteriovenous malformations (AVMs) which were suspicious for bleeding, although a definitive bleeding site was not established. Cauterization of the AVMs did not result in stability of the enrollee's anemia. The documentation in the case file supports that endoscopy and colonoscopy have failed to reveal a source of bleeding in this 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 a WCE have been met.Therefore, we decided that the Plan has to pre-approvea Wireless Capsule Endoscopy (WCE) (91110).If the Plan does not agree with our decision,they can ask usto 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 toopen the case again, we will send you a letter.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve psychotherapy services to be provided January 8, 2020 to June 30, 2020.
You asked the Plan to pre-approve the psychotherapy sessions. You say that the outpatient mental health services are medically necessary. The Plan denied your request. The Plan says rules for coverage have 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 the psychotherapy sessions. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this patient is not showing any symptoms of suicidal ideation, homicidal ideation, psychosis, severe mood symptoms, substance abuse, physical aggression or self-injurious behavior. The requested number of sessions are excessive. 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 psychotherapy sessions have not been met. Therefore, we decided that the Plan does not have to pre-approve psychotherapy services to be provided January 8, 2020 to June 30, 2020.
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 requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH 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 admission to a LTACH is not medically necessary. Our physician reviewer found the enrollee was admitted to ICU with Influenza A and Strep pneumonia. Long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not provide clinical services that are materially different than those of short term acute care hospitals. In this case, ongoing care needs include respiratory support with tracheostomy care, nebulizer treatments, telemetry with indicated cardiovascular infusions, intravenous antibiotics, surveillance laboratory studies, and therapy services. 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. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan. Consequently, 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: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the waterproof tape, gauze, and conforming bandage provided on October 8, 2019.
You asked the Plan to pay for the waterproof tape, gauze, and conforming bandage. You say that this claim was denied in error. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.
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 the waterproof tape, gauze, and conforming bandage provided on October 8, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Basaglar Kwikpen 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 the Basaglar Kwikpen 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve high-dose laser treatment for knee pain.You asked the Plan to pre-approve the high-dose laser treatment. You say that you feel this should be covered to help you avoid a knee replacement surgery.The Plan denied your request. The Plan says this is currently an experimental treatment.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 high-dose laser treatment. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this 67 year old man has chronic bilateral knee pain. He has tried and failed Physical therapy. He has a Deep Brain Stimulator for tremor. He has been advised to try warm soaks, rest and pain medications. The request is for high dose laser therapy. This is an experimental/ investigational procedure. It has not been ordered by a licensed medical professional. The service is not considered medically reasonable and necessary.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the high-dose laser treatment have not been met.Therefore, we decided that the Plan does not have to pre-approve high-dose laser treatment for knee pain.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve proton beam radiotherapy (PBRT) for prostate cancer treatment.You asked the Plan to pre-approve the PBRT services. You say that PBRT is superior to any other radiation therapy for prostate cancer since it reduces damage to healthy tissues.The Plan denied your request. The Plan says there is insufficient evidence to prove that PBRT is superior to standard treatments.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 PBRT services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the recently released ASTRO model policy for proton therapy states "In the treatment of prostate cancer, the use of PBT is evolving as the comparative efficacy evidence is still being developed. In order for an informed consensus on the role of PBT for prostate cancer to be reached, it essential to collect further data, especially to understand how the effectiveness or proton therapy compares to other radiation modalities." and emphasizes the need to enroll patients on studies. The bottom line is that proton therapy for prostate cancer is not experimental, and in fact is an accepted treatment approach. However, any potential benefit or detriment of proton therapy over standard IMRT is an investigational question (being pursued in randomized studies-i.e. for intermediate to low risk prostate cancer. To date, there are no compelling data to suggest that proton therapy is superior to or more beneficial than IMRT/IGRT. The generally accepted standard of care for prostate cancer is to only offer proton beam therapy on clinical trials, and to not routinely offer it to patients.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 PBRT services have not been met.Therefore, we decided that the Plan does not have to pre-approve proton beam radiotherapy (PBRT) for prostate cancer treatment.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an injection to be provided by an out of network (OON) provider.You asked the Plan to pre-approve an injection. You say that these services are medically necessary.The Plan denied your request. The Plan says the criterion is not met for the injection.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 an injection 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-approveContour Next Test Strips.You asked the Plan to pre-approvethe non-preferred brand of test strips. You say that learning a new monitor adds undue stress and confusion and may hinder the enrollee's compliance.The Plan denied your request. The Plan says the enrollee is required to obtain test strips from preferred vendors.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. There is no documentation that the non-preferred brand is necessary to avoid an adverse medical outcome. Based on this information, we decided that Medicare rules for coverage of the non-preferred brand of test strips have not been met.Therefore, we decided that the Plan does not have to pre-approveContour Next Test Strips.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approveTinnitus Retraining Therapy (TRT).You asked the Plan to pre-approveTRT. You say that your son has hadringing in his ear since September 18, 2019, and the Ear, Nose and Throat specialist has advised this therapy.The Plan denied your request. The Plan says the evidence is insufficient to show it is medically necessary versus not medically necessary, therefore the treatment at this time is deemed investigational and experimental.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 TRT. Our reviewer says that under the enrollee's Plan, there is insufficient evidence in the published medical literature to show that this service/therapy is as safe as standard services/therapies or provides better long-term outcomes than current standard services/therapies. Our physician reviewer found the management of tinnitusshould include diagnosis and elimination of precipitating factors. In many cases, the cause of tinnitus cannot be identified warranting treatment of the symptom itself. At present, no universal treatment has been found effective in all patients and options are heavily dependent on the severity and perception of the condition. Treatment might range from counseling and dietary modification to acupuncture and relaxation therapy. Medications (antianxiety and antidepressants) may be helpful. In this case, thereare alternative established treatments. In a study of the effects of tinnitus retraining therapy versus the standard of care there were few differences.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of TRT have not been met.Therefore, we decided that the Plan does not have to pre-approveTinnitus Retraining Therapy (TRT).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services provided to the enrollee on May 16, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the records do not support the services billed.
The Plan must follow Medicare rules. Medicare rules say that a physician order must be present for labs to be covered. The documentation submitted did not include a physician order/lab requisition or medical records stating exactly tests were to be performed. 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 pay for drug testing services provided to the enrollee on May 16, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a chest x-ray (71045-26-59) provided on July 30, 2019.
You asked the Plan to pay for the chest x-ray. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says this service was not billed with the appropriate modifier.
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 71045-26-59 is not supported in the medical record. Specifically, the x-ray at issue was not billed on the same claim as the service that was processed and paid. The use of modifier -59 requires that the provider bills all services performed on one day on the same claim. Based on this information, we decided that Medicare rules for coverage of the chest x-ray have not been met. Therefore, we decided that the Plan does not have to pay for a chest x-ray (71045-26-59) provided on July 30, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that the requested admission to a LTACH is medically necessary.The Plan denied your request. The Plan says the requested admission to a LTACH 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 admission to a LTACH is not medically necessary. Our physician reviewer found based on the documentation provided, the enrollee is currently undergoing treatment at an acute care hospital (ACH) for end-stage chronic obstructive pulmonary disease and an evolving pulmonary mass. The enrollee is not intubated/ventilated. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care needs.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-approvelong term acute care hospital (LTACH) services.
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 requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH 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 admission to a LTACH is not medically necessary. Our physician reviewer found the enrollee was admitted to acute care on 2/15/20 at the request of the enrollee's son. The enrollee was septic on admission with acute kidney injury and lactic acidosis. Long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not provide clinical services that are materially different than those of short term acute care hospitals. In this case, ongoing care needs include respiratory support with oxygen supplementation, surveillance laboratory studies, tube feeding, decubitus ulcer wound care, and therapy services. 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. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan. Consequently, 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Armour Thyroid tablets.You asked the Plan to pre-approve Armour Thyroid tablets. You say that you would like the Plan to reconsider their denial.The Plan denied your request. The Plan says Armour Thyroid tablets are not covered under the enrollee's Medicare Part B benefit. The Plan says they believe the enrollee's pharmacy benefit manager is Express Scripts.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 Armour Thyroid tablets.Benefits for Armour Thyroid tablets may be available under Medicare Part D.Contact the Plan that administers PartD benefits for further information concerning any benefits and appeal rights.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve psychotherapy sessions (90837 x10).You asked the Plan to pre-approve the outpatient mental health services. You say that the services are medically necessary.The Plan denied your request. The Plan says 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 the outpatient mental health services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the record shows no improvement from previous psychotherapy services. The record shows the enrollee is unlikely to benefit from the number of additional sessions requested.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 outpatient mental health services have not been met.Therefore, we decided that the Plan does not have to pre-approve psychotherapy sessions (90837 x10)