Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve implantation of a CardioMEMS HF System.
You asked the Plan to pre-approve implantation of a CardioMEMS HF System. You say that the requested implantation of a CardioMEMS HF System is medically necessary. The Plan denied your request. The Plan says the requested implantation of a CardioMEMS HF System is not medically necessary.
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 implantation of a CardioMEMS HF System. Our reviewer says that the requested implantation of a CardioMEMS HF System is not medically necessary. Our physician reviewer found the enrollee is with a history of hypertension, obstructive sleep apnea, obesity, smoking, atrial fibrillation and NYSHA Class III congestive heart failure with preserved ejection fraction requiring hospitalization. In this circumstance therapy change based on data obtained from a CardioMEMs device has been demonstrated in only one 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 uncertain at 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 implantation of a CardioMEMS HF System have not been met. Therefore, we decided that the Plan does not have to pre-approve implantation of a CardioMEMS HF System.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc-One (J7325).
You asked the Plan to pre-approve the Synvisc-One. You say that Synvisc-One is medically necessary for treatment of the member's condition. The Plan denied your request. The Plan says Medicare's compendia and coverage determinations do not support using this drug to treat hip osteoarthritis pain.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 Synvisc-One. Our reviewer says that review of compendia does not support Synvisc-One for the treatment of hip osteoarthritis. Our physician reviewer found without the support of the documentation, medical necessity cannot be determined. 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 Synvisc-One have not been met. Therefore, we decided that the Plan does not have to pre-approve Synvisc-One (J7325).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says daily skilled nursing and daily skilled therapy in a SNF setting is not covered.
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 the admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 the admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve out-of-network hemodialysis services.
You asked the Plan to pre-approve out-of-network hemodialysis services. You say that the services are necessary. The Plan denied your request. The Plan says the enrollee has elected hospice so all of their medical benefits are covered by original Medicare and are not eligible for coverage by the health plan.
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 when the request for service at issue in this appeal was made. Therefore, we decided that the Plan does not have to pre-approve out-of-network hemodialysis services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a heavy duty wheelchair and elevating leg rests.You asked the Plan to pre-approvea heavy duty wheelchair (K0006) and elevating leg rests (K0195). You say that because of high risk of falling the enrollee needsa heavy duty wheelchair and elevating leg rests.The Plan denied your request. The Plan says there is no documentation on MRADLs or that the enrolleecannot use a walker or cane.The Plan follows Medicare rules. Medicare rules say that a manual wheelchair will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, or the patient's condition can be ameliorated by a walker or cane, or the enrollee's home does not provideadequate accessfor use of the manual wheelchair.The filedoes not showthat the enrolleehas a mobility deficit that impairs theirparticipation in MRADLs, or that theircondition cannot be improvedby a walker or cane. There is no home assessment documentation.This means that Medicare rules for coverage of a PMD have not been met.Therefore, we decided that the Plan does not have to pre-approvea heavy duty wheelchair and elevating leg rests.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vascepa Cap 1GM.You asked the Plan to pre-approveVascepa Cap 1GM. You say that the requested medication is necessary.The Plan denied your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit or a separate pharmacy benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage.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-approveVascepa Cap 1GM.Benefits for Vascepa Cap 1GMmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that you are appealing the denial for in house rehab for Encompass. The Plan denied your request. The Plan says the enrollee does not meet the criteria for IRF admission. The enrollee can safely receive the care needed at a lower level of care such as a skilled nursing facility.
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 Based on review of available records, the enrollee does not meet criteria for coverage for an IRF admission. The enrollee is generally medically stable, with no recent neurological or orthopedic events except old stroke with functional decline and there is no evidence of complex medical issues that require monitoring by an inpatient physical medicine and rehabilitation physician three times per week or need for acute rehab nursing care. While he may benefit from continuing physical therapy and occupational, there is no evidence of need for an intensive therapy program with therapy 3 hours per day with frequent physician oversight and an interdisciplinary approach to rehabilitation 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.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc-One for the enrollee.
You asked the Plan to pre-approve Synvisc-One. You say that this is medically necessary. The Plan denied
your request. The Plan says that they did not receive documentation supporting the medical necessity for a step
therapy exception.
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 Synvisc-One. Our reviewer says that
Synvisc-One is not medically reasonable and necessary for the enrollee in this case. The provided medical
records do not indicate that the enrollee has tried and failed Orthovisc and Monovisc or that they would likely
be less effective and/or likely have adverse effects for the enrollee. Our physician reviewer found that the
enrollee's condition does not meet step therapy criteria for Synvisc-One.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Synvisc-One have not been met. Therefore, we decided that the Plan does not
have to pre-approve Synvisc-One for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion of a chest wall respiratory sensor (Inspire procedure).You asked the Plan to pre-approveInspire procedure. You say that you are unable to tolerate continuous positive airway pressure (CPAP) treatment and feel you have no other viable options than the Inspire procedure.The Plan denied your request. The Plan says the denial of authorization for this service is correct, because the Inspire procedure is not covered by Medicare currently and further research is required to fully evaluate whether this device meets Medicare coverage requirements.The Plan must follow Medicare rules. Medicare rules say that the Inspire procedure is not considered medically necessary and is not covered by Medicare at this time. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Inspire procedure have not been met.Therefore, we decided that the Plan does not have to pre-approveinsertion of a chest wall respiratory sensor (Inspire procedure).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe reSET-O Application.You asked the Plan to pre-approvethe reSET-O Application. You say that the enrollee has tried and failed various treatments.The Plan denied your request. The Plan says the mobile application system does not directly treat a medical condition and is not covered by Medicare.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured.Therefore, we decided that the Plan does not have to pre-approvethe reSET-O Application.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Continuous Glucose Monitoring (CGM) system.
You asked the Plan to pre-approve a CGM. You say that the enrollee needs a CGM. The Plan denied your request. The Plan says the clinical documentation does not support need for a CGM.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered only when they are medically reasonable and necessary and replace a blood glucose monitor. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a Continuous Glucose Monitoring (CGM) system.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6531, A6532 and A6545.
You asked the Plan to pre-approve the compression stockings. You say that you have significant discomfort that is limiting your mobility and you are concerned about deconditioning should you continue to avoid physical activity. The Plan denied your request. The Plan says the requested items are not covered by Medicare.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6531, A6532 and A6545 are noncovered 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 A6531, A6532 and A6545.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve varicose vain treatment to be provided by an out of network (OON) provider. You asked the Plan to pre-approve varicose vain treatment. You say that this is a continuity of care. The Plan denied your request. The Plan says there are in-network providers available for these services. 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 varicose vain treatment to be provided by an out of network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve physical therapy. You say that you would like to appeal the denial of out-of-network physical therapy. The Plan denied your request. The Plan says you can see in-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-approve physical therapy 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-approve a shower chair.You asked the Plan to pre-approve a shower chair. The Plan denied your request. The Plan says that this is not covered under your contract or the Medicare program under any normal circumstances.The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item.Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered to the enrollee on July 26, 2019. You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says there is no valid physician order. The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician. We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 pay for the drug testing rendered to the enrollee on July 26, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Asmanex HFA 100mcg inhaler for the enrollee.
You asked the Plan to pre-approve the inhaler. You say that this is medically necessary. The Plan denied your request. The Plan says this is usually self-administered by patients.
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 Asmanex HFA 100mcg inhaler for the enrollee.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the outpatient mental health services (90836)
You asked the Plan to pre-approve the outpatient mental health services. You say that in-network providers are too far. The Plan denied your request. The Plan says there are in-network providers available that can render the service at issue. Three of the providers are within 2 miles.
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 the outpatient mental health services (90836)
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on September 12, 2019.
You asked the Plan to pay for the drug testing services. The Plan denied your request. The Plan says the
documentation submitted did not include a valid physician order/lab requisition or medical records for the
billed date of service; therefore the billed codes cannot be verified.
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the
medical record, his or her intent that the test be performed.
We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab
requisition stating exactly which testing was to be performed. Based on this information, we decided that
Medicare rules for coverage of the drug testing services have not been met. Therefore, we decided that the Plan
does not have to pay for the drug testing services provided on September 12, 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 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 is status post a fall at home with cervical spine injury requiring fusion. The enrollee has had subsequent tracheostomy following edema in her airway after C-spine surgery and resultant PEG placement. At last note, the enrollee is on a trach collar. The enrollee has had some cardiac rhythm abnormalities also. The enrollee is doing well at current level of care and progressing. The enrollee is currently on a trach collar. The enrollee has no complex wounds. The enrollee is on PEG feedings. There is no indication of need for LTACH level of care based on the records reviewed. The requested LTACH admission is not 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 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.