Persius/hicric huggingface dataset:
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 are appealing with medical records. The Plan denied your request. The Plan says the denial of authorization for LTACH service is correct.
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 does not require services at the LTACH that are not already available and covered by the current acute care hospital. Therefore, this request for transfer to LTACH is not 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 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6533.
You asked the Plan to pre-approve the compression stockings. You say that the member complies with the
diagnosis for the compression stocking. The Plan denied your request. The Plan says the member's condition
does not meet the rules for approval.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6533 are
non-covered because they do not meet the statutory definition of a surgical dressing.
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression
stockings identified with code A6533.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve disposable sensors for use with an interstitial continuous
glucose monitoring (CGM) system (A9276).
You asked the Plan to pre-approve disposable sensors. You say that this is medically necessary due to
Addison's disease. The Plan denied your request. The Plan says supplies for the type of monitor you have are
not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that CGMs and supplies are only covered when they
are therapeutic as defined above.
We looked at the file and Medicare rules. The items you have requested are supplies used with a nontherapeutic
CGM. These supplies are not covered by Medicare. Based on this information, we decided that
Medicare rules for coverage of disposable sensors have not been met. Therefore, we decided that the Plan does
not have to pre-approve disposable sensors for use with an interstitial continuous glucose monitoring (CGM)
system (A9276).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Repatha Sure Injections 140mg/Ml.
You asked the Plan to pre-approve Repatha Sure Injections. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says Repatha Sure Injections are not covered under the enrollee's Medicare Part B benefit.
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 Repatha Sure Injections 140mg/Ml.
Benefits for Repatha Sure Injections 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve routine transportation services (A0120).
You asked the Plan to pre-approve the routine transportation services. You say that routine transportation is necessary for your upcoming procedure. The Plan denied your request. The Plan says this service is not covered under your benefit package.
The Plan must follow Medicare rules. Medicare does not cover transport in a vehicle that is not an ambulance. The Plan follows the same rule. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Medicare rules for coverage of the routine transportation services have not been met. Therefore, we decided that the Plan does not have to pre-approve routine transportation services (A0120).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a leadless pacemaker for the enrollee.
You asked the Plan to pre-approve the requested service. You say that the enrollee will likely dislodge a regular pacer. The Plan denied your request. The Plan says leadless pacemakers are non-covered when furnished outside of a CMS approved study.
The Plan must follow Medicare rules. Medicare rules say that CMS covers leadless pacemakers when procedures are performed in FDA approved studies. We looked at the file and Medicare rules. The records provided do not show that the enrollee is participating in a Medicare-approved study. Based on this information, we decided that Medicare rules for coverage of the requested service have not been met. Therefore, we decided that the Plan does not have to pre-approve a leadless pacemaker for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Rituxan for the enrollee.
You asked the Plan to pre-approve Rituxan. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says that the enrollee must have taken the other drug(s) preferred by our plan that are used to treat the same medical issue.
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 Rituxan. Our reviewer says that Rituxan is not medically reasonable and necessary for the enrollee in this case. Rituxan is being requested for the treatment of relapsing, remitting membranous neuropathy. The enrollee has not trialed prednisone, methylprednisolone, Leukeran, cyclophosphamide, cyclosporine, and tacrolimus. Step therapy, as outlined by the plan, requires these be trialed first. The documentation does not outline contraindications or reasons these medications were not considered. Our physician reviewer found the enrollee's condition does not meet step therapy criteria for Rituxan.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Rituxan have not been met. Therefore, we decided that the Plan does not have to pre-approve Rituxan for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ondansetron tablets 8mg.
You asked the Plan to pre-approve Ondansetron tablets. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says Ondansetron tablets are not covered under the enrollee's Medicare Part B benefit.
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 Ondansetron tablets 8mg.
Benefits for Ondansetron tablets 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that your physical therapist has recommended SNF care. The Plan denied your request. The Plan says that the assistance you currently require could be appropriately delegated to caregivers and do not require only professionals to provide.
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 reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) 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. The Plan denied your request. The Plan says LTACH 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 that in the case of this enrollee, current status includes dependency on breathing support, nutritional support, antibiotic treatment, and wound care (uncomplicated). The enrollee requires ongoing pulmonary management on ventilation, IV antibiotics and monitoring which could be performed at the current acute care facility temporarily until a lower level of care facility is available. Anoxic brain injury suggests that there is unlikely to be significant benefit from long-term acute care at the current facility or at the proposed LTACH. The enrollee does not require services at the LTACH that are not already available and covered by the current acute care hospital. Therefore, this request for transfer to the proposed LTACH will be considered not medically necessary based on the documentation provided. 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the lumbar spine.
You asked the Plan to pre-approve these services. You say that physical therapy hasn't worked. The Plan denied your request. The Plan says the services are not medically necessary.
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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the records show you have complaints of pain in both hips with mild back discomfort for about two months. There is no history of trauma. There has been no previous treatment. You have no red flag findings and have not had a trial of conservative therapy. There is no documentation that the treatment plan would be modified based on results of an MRI. The MRI is not reasonable or medically necessary 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the lumbar spine.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for needle electromyography (95861) and neuromuscular junction testing (95937) provided on November 28, 2018.
You asked the Plan to pay for the needle electromyography and neuromuscular junction testing. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not include documentation of needle electromyography; 2 extremities with or without related paraspinal areas. Additionally, documentation indicates that Train of Four Testing/Monitoring was performed which does not meet the CMS guidelines of CPT code 95937.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 95861 is needle electromyography; 2 extremities with or without related paraspinal areas. The CPT Manual definition of code 95937 is neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method. We asked our coder 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 the needle electromyography and neuromuscular junction testing. Our reviewer says that 95861 does not meet criteria for billing or reimbursement consideration.
The medical records provided do not document Needle electromyography; 2 extremities with or without related paraspinal areas, therefore this service cannot be verified. Our reviewer found 95937 does not meet criteria for billing or reimbursement consideration. The medical records provided do not document Neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method. The provided medical documentation indicates train of four testing was performed. It is not appropriate to bill CPT 95937 to represent train of four testing per Medicare and AMA guidelines. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the needle electromyography and neuromuscular junction testing have not been met. Therefore, we decided that the Plan does not have to pay for needle electromyography (95861) and neuromuscular junction testing (95937) provided on November 28, 2018.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee requires an extensive vent weaning effort. The Plan denied your request. The Plan says the enrollee is receiving appropriate care at the current acute care facility.
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 physician reviewer found that the enrollee is currently undergoing treatment at an acute care hospital (ACH). The enrollee was apparently treated for pneumonia and aspiration. The enrollee required intubation/ventilation and subsequently received a tracheotomy. The enrollee has not tolerated ventilator weaning. It is unclear that weaning and/or decannulation can be achieved. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve out-of-area physician services for the enrollee.
You asked the Plan to pre-approve the out-of-area services. The Plan denied your request. The Plan says there is no urgent or emergent need for the enrollee to receive care from an out-of-network specialist.
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and pre-approved care. We looked at the file, and Medicare rules. The services do not appear to be urgent or emergent. The need for services was known prior to leaving the service area. Based on this information, we decided that Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve out-of-area physician services for the enrollee.
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. The Plan denied your request. The Plan says LTACH 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 that in the case of this enrollee, current status includes dependency on breathing support, nutritional support, wound care (uncomplicated), and hemodialysis. The enrollee requires ongoing physical therapy and monitoring which could be performed at the current acute care facility until breathing support is successfully weaned. As breathing appears to be improving sufficiently enough to suggest a successful weaning should likely occur in less than 25 days, transfer to LTACH would not be appropriate. The enrollee does not require services at the LTACH that are not already available and covered by the current acute care hospital. Therefore, this request for transfer to the proposed LTACH will be considered not medically necessary based on the documentation provided. 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 1.5mg Stimate SOL.
You asked the Plan to pre-approve the Stimate. You say that the Stimate is medically necessary for this
member. The Plan denied your request. The Plan says this medication falls under Part D coverage, not Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 1.5mg Stimate SOL.
Benefits for Stimate 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 the Inspire Upper Airway Stimulation (UAS) device (64568 and 0466T).
You asked the Plan to pre-approve the Inspire Upper Airway Stimulation (UAS) device. You say that the requested Inspire Upper Airway Stimulation device is medically necessary. The Plan denied your request. The Plan says the requested Inspire Upper Airway Stimulation device is not covered by Medicare or the plan.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. The Inspire Upper Airway Stimulation (UAS) device (also known as a hypoglossal nerve stimulator) with procedure code 0466T is currently excluded from Medicare coverage as not proven effective or not medically reasonable or necessary. Based on this information, we decided that Medicare rules for coverage of the Inspire Upper Airway Stimulation (UAS) device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Inspire Upper Airway Stimulation (UAS) device (64568 and 0466T).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for injections (20553) provided on March 22, 2019.
You asked the Plan to pay for the injections. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the submitted medical records indicate that injection single or multiple trigger point was performed, however do not indicate 3 or more muscles were performed. In addition, the submitted medical records do not indicate the names of the muscles.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 20553 is injection(s); single or multiple trigger point(s), 3 or more muscles. We asked our coder 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 the injections. Our reviewer says that 20553 does not meet criteria for billing or reimbursement consideration. Our reviewer found the medical record provided does not include documentation of an injection(s); single or multiple trigger points, 3 or more muscles being performed on March 22, 2019, therefore, the service cannot be validated. The documentation does not document the
names of the muscles to help confirm the services billed. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the injections have not been met. Therefore, we decided that the Plan does not have to pay for injections (20553) provided on March 22, 2019.