Persius/hicric huggingface dataset:
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 the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is 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 considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for 
surgical treatment of a hip fracture after a fall. Medical conditions are stable. There are no medical needs 
requiring inpatient admission. There are no complex nursing or rehabilitation needs. You do 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 you 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 IRF admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveAbraxane to be provided by an out of network (OON) provider.You asked the Plan to pre-approveAbraxane. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested services can be provided by a 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-approveAbraxane to be provided by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan
denied your request. The Plan says the stay 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 there is no documentation provided necessitating admission to a LTACH. The
enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at
the LTACH that are not available at the acute care hospital where they are 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. The requested LTACH services are not medically necessary, reasonable, and
appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only
on an inpatient basis.
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 LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea power operatedvehicle.You asked the Plan to pre-approvea power operated vehicle. You say that you need this for outside mobility and to run errands.The Plan denied your request. The Plan says this is not covered for outside use.The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home.Therefore, we decided that the Plan does not have to pre-approvea power operated vehicle
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approvethe Eylea 1 mg injection.You asked the Plan to pre-approveEylea. You say that this service is medically necessary.The Plan denied your request. The Plan says that the request does not meet step therapy requirements.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 therelevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Eylea. Our reviewer says that step therapy requirements have been met. Our physician reviewer found you have received intravitreal injections of Lucentis (ranibizumab) for your condition. Based on the Comparison of Age-related Macular Degeneration Treatments Trials: Lucentis-Avastin Trial, Ranibizumab is equivalent to Bevacizumab in the treatment of this condition and has been FDA approved for this condition.The patient has not failed therapy with Lucentis; however, the practice of switching to Eylea (aflibercept) can also be helpful to lengthen the interval treatment time between injections. Because of the less frequent dosing, the patient will be able to undergo fewer injections over a time which is safer overall for the patient.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Eylea have been met.Therefore, we decided that the Plan has to pre-approvethe Eylea 1 mg injection.
f the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide toopen the case again, we will send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pay for IRF care. You say that IRF care is medically necessary. The Plan denied your request. The Plan says rules for IRF care have not been met.
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 pay for IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. In addition, 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. Finally, 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. 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 pay for acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Favorable

We decided that the Plan does not have to pay forlab services provided to the enrollee on November 19, 2019.You asked the Plan to pay forthis service. You say that this claim should be paid.The Plandenied your request. The Plan says Medicare billing criteria are not met. Maximus overturned the Plans denial. The Plan requested a reopen and provided additional information regarding claim A. The Plan states the claim number referenced or claim A was denied due to a billing error. The Plan stated that this claim denied because it was billed with an inappropriate diagnosis code, M48.062-Spinal stenosis, that is not covered per NCD 190.15.The records show the provider submitted their appeal with a corrected claim changing the primary diagnosis to E78.5 for Hyperlipidemia, unspecified, which means admission to incorrect billing.  The corrected claim also added HCPC code P9604 for Travel allowance, which was not previously submitted. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes.In this case, the claim under appeal or claim A, denied appropriately due to an incorrect diagnosis code per Medicare billing guidelines. The Plan notes a corrected claim was submitted. Therefore, we decided that the Plan does not have to pay forlab services provided to the enrollee on November 19, 2019under the claim A.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forintraoral -complete series of radiographic images (D0210) provided on September 15, 2020.You asked the Plan to pay forthe dental services. You say that the services were provided based on medical necessity.The Plan denied your request. The Plan says you exhausted your benefit frequency limit.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.You have exceeded the frequency limitation for the panoramic x-ray. You received the services on November 04, 2019, and the plan allows it once every fiveyears. The health plan contract says that full mouth x-rays (which include bitewings) are payable once in a fiveyear period.Therefore, we decided that the Plan does not have to pay forintraoral -complete series of radiographic images (D0210) provided on September 15, 2020
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan has to pre-approvethe magnetic resonance imaging (MRI) of the leg (73718).You asked the Plan to pre-approvethe MRI of the leg. You say that the services requested are medically necessary.The Plan denied your request. The Plan says that the MRI of the leg is not medically necessary in this case.The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 the MRI of the leg. Our reviewer says that the service is medically necessary. Our physician reviewer found the MRI is medically reasonable and necessary. The enrollee's right foot was painful to touch, swollen, and discolored. A plain x-ray only revealed soft tissue swelling.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 MRI of the leg have been met.Therefore, we decided that the Plan has to pre-approvethe magnetic resonance imaging (MRI) of the leg (73718).If the Plandoes not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This doesnot happen often. If we decide to open the case again, we will send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea semi-electric hospital bed and a power scooter.You asked the Plan to pre-approvethe items. You say that this is medically necessary.The Plan denied your request. The Plan says the requested items cannot be approved.The Plan must follow 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 rules also say that a semi-electric hospital bed may be considered medically necessary when the patient:1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or2. Requires attachments which can only be attached to a hospital bed; AND3. Requires frequent changes in body position and/or has an immediate need for a change in body position.
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 items. Our reviewer says that the requested items are not medically reasonable or necessary. Our physician reviewer found based on the medical records provided, there is no documentation that your condition requires positioning of the body in ways not feasible in an ordinary bed. There is no documentation of a requirement for frequent changes in body position or immediate changes in body position. There is no need for special attachments that cannot be fixed and used on an ordinary bed. The requested bed is not medically reasonable or necessary.Our physician reviewer found that there is no documentation of a personal mobility deficit that impairs participation in MRADLs. There is no documentation that this deficit cannot be helped by the use of a walker, cane, or manual wheelchair. There is no documentation that you would be able to operate the scooter. The requested power scooter is 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 items have not been met.Therefore, we decided that the Plan does not have to pre-approvea semi-electric hospital bed and a power scooter.
Appeal type: Drugs
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 the CGM. You say that the CGM is 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 a Continuous Glucose Monitor is covered when the beneficiary is insulin-treated with multiple (three or more) daily injections of insulin. We looked at the file and Medicare rules. The record does not show that the enrollee is treated with multiple daily insulin injections. Based on this information, we decided that Medicare rules for coverage of the CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the requested admission to an IRF is medically necessary.The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.The Plan must followMedicare 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 thePlan 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 notrequire an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for myocardial infarction and coronary artery bypass grafting. 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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea CardioMEMS HF system.You asked the Plan to pre-approvea CardioMEMS HF system. You say that the requested CardioMEMS HF system is medically necessary.The Plan denied your request. The Plan says the requested CardioMEMS HF system is not medically necessary.The Plan must follow Medicare rules. Medicare rules say that items andservices 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 a CardioMEMS HFsystem. Our reviewer says that the requested CardioMEMS HF system is not medically necessary. Our physician reviewer found in this circumstance therapy change based on data obtained from a CardioMEMs device has been demonstrated in only one randomized prospective trial to help reduce hospital readmission compared to standard medical therapy. Moreover, concerns have been raised about potential bias in this trial calling into question the results. Therefore, the efficacy of the CardioMEMS device is uncertainat this time according to leading authorities and not recommended in current guidelines for the treatment of heart failure. Medicare coverage criteria are not met since the device should still be considered experimental or investigational.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 CardioMEMS HF system have not been met.Therefore, we decided that the Plan does not have to pre-approvea CardioMEMS HF system.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Dupixent injectable medication.
You asked the Plan to pre-approve this medication. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says this medication is not a covered benefit under the member's contractual policy.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drug requested here is not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve the Dupixent injectable medication.
Benefits for this medication 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve TRELEGY ELLIPTA for the enrollee.
You asked the Plan to pre-approve this drug. You say that the enrollee is well controlled with the use of this
drug. 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 TRELEGY ELLIPTA 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea Freestyle Libre continuous glucose monitor (CGM).You asked the Plan to pre-approvea Freestyle Libre CGM. You say that you need this because you cannot prick your finger.The Plan denied your request. The Plan says the criteria for coverage are not met.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 you do not 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. Based on this information, we decided that Medicare rules for coverage of a Freestyle Libre CGM have not been met.Therefore, we decided that the Plan does not have to pre-approvea Freestyle Libre continuous glucose monitor (CGM)
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea referral to an out-of-network neurology provider.You asked the Planto pre-approvethe referral. You say that this is medically necessary.The Plandenied your request. The Plansaysgenerally, care must be received from a 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 theitems/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 Plandoes not haveto pre-approvea referral to an out-of-network neurology provider