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

We decided that the Plan has to pre-approve a Watchman Device.

You asked the Plan to pre-approve a Watchman Device. You say that the clinical documentation supports medical necessity for the requested device. The Plan denied your request. The Plan says that the documentation fails to confirm a clinical issue with the currently prescribed anticoagulation therapy. The Plan says that there is no documentation of intolerance to current therapy or bleeding episodes. The Plan says that the left atrium appendage closure would be considered not reasonable and necessary.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 a Watchman Device. Our reviewer says that a Watchman Device is considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has a high risk of embolic stroke with a CHA2DS2VASc score of 6 and an elevated risk of bleeding based on her HASBLED score of 3. In addition, she is unable to afford her Apixaban therapy which, based on most recent data, provides the safest and most effective anticoagulation in this clinical situation, especially in the setting of congestive heart failure. This is especially true as compared to attempting to switch to Warfarin with home monitoring of therapy which, without a motivated patient, is unlikely to be nearly as effective in maintaining effective anticoagulation in this woman who is also at higher risk of bleeding episodes because of the above-mentioned risks. For these reasons, the enrollee meets the medical necessity criteria for use of the Watchman atrial appendage closure device. 

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 Watchman Device have been met. Therefore, we decided that the Plan has to pre-approve a Watchman Device.

If 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 to open the case again, we will send you a letter.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
You asked the Plan to pre-approve continued services. The Plan denied your request. The Plan says you do not require daily skilled therapy services on an inpatient basis.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 continued services. Our physician reviewer found that you are at a moderate assist for lower body dressing, minimal assist for hygiene and grooming, and moderate assist for toileting. You do not have documented skilled nursing or skilled therapy needs. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of your condition. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Intracept procedure.

You asked the Plan to pre-approve Intracept Intraosseous Nerve Ablation system of the basivertebral nerve (BVN) (22899) and destruction of intraosseous basivertebral nerve, first two vertebral bodies, including imaging guidance (e.g., fluoroscopy), lumbar/sacrum (C9752). You say that this procedure is medically necessary and the most effective treatment for the enrollee at this time. The Plan denied your request. The Plan says there are not enough studies on Intracept to show it is safe and effective.

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 Intracept Intraosseous Nerve Ablation system of the basivertebral nerve (BVN) (22899) and destruction of intraosseous basivertebral nerve, first two vertebral bodies, including imaging guidance (e.g., fluoroscopy), lumbar/sacrum (C9752). Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this is still considered an experimental/ investigational procedure. Therefore, the request is considered not medically reasonable or necessary. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Intracept Intraosseous Nerve Ablation system of the basivertebral nerve (BVN) (22899) and destruction of intraosseous basivertebral nerve, first two vertebral bodies, including imaging guidance (e.g., fluoroscopy), lumbar/sacrum (C9752) have not been met. Therefore, we decided that the Plan does not have to pre-approve an Intracept procedure.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.
You asked the Plan to pre-approve SNF care. You say that you are not at your baseline functional status. The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs. You do not require skilled nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a SNF setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve respiratory assist device with Bi-Level Pressure (BiPAP) (CPT code E0470RR).
You asked the Plan to pre-approve the DME. You say that you were advised that you could not leave the hospital without this device and now it has been denied. The Plan denied your request.
The Plan says that there is no clinical evidence to support the medical necessity for the respiratory assist device, bi-level pressure capability, without backup rate.
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 DME. Our physician reviewer found BiPAP is considered medically necessary for you. You have chronic obstructive pulmonary (COPD) and obstructive sleep apnea (OSA), with frequent COPD exacerbations. You have chronic hypoxic and hypercarbic respiratory failure. You were intolerant of continuous positive airway pressure therapy (CPAP) in the past. You were hospitalized in August with severe hypercarbic respiratory failure and did well with BiPAP. You are doing well at home on BiPAP. It is likely that continued use of nightly BiPAP will help prevent future hospitalizations. BiPAP should be approved for three (3) months, with further approval pending confirmation of compliance with use. 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 DME have been met. Therefore, we decided that the Plan has to pre-approve respiratory assist device with Bi-Level Pressure (BiPAP) (CPT code E0470RR).
If 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 to open the case again, we will send you a letter.
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 admission to an LTACH is medically necessary. The Plan denied your request. The Plan says the admission to an 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 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. You are receiving appropriate care at the present acute care hospital. You do not require services at the LTACH that are not available at the present setting where you are currently receiving care. There are no services available at the LTACH that you require that are not available at the health care setting being offered by the health plan. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met.
Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve chiropractic services (99203).
You asked the Plan to pre-approve the chiropractic services. You say that the services are medically necessary. The Plan denied your request. The Plan says the services requested are not a covered benefit.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pre-approve chiropractic services (99203).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT code(s): 22869 and 22870), for the enrollee.
You asked the Plan to pre-approve the surgery. You say that the surgery is necessary. The Plan denied your request. The Plan says the services are considered experimental and investigational.
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 surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental. More research is needed to show safety and efficacy. 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 surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT code(s): 22869 and 22870), for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex Superion Spacer device.

You asked the Plan to pre-approve the Vertiflex device. You say that you would like reconsideration because the requested device is medically reasonable and necessary. The Plan denied your request. The Plan says the requested service is considered experimental.

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 Vertiflex device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this procedure is still considered experimental/ investigational and its role in the treatment of spinal stenosis is not defined by specialty societies. 

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 Vertiflex device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex Superion Spacer device.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bevacizumab and doxorubicin (Q2050, Q5118).
You asked the Plan to pre-approve bevacizumab and doxorubicin. You say that the drugs are medically necessary. The Plan denied your request. The Plan says the requested chemotherapy combination is not approved for the enrollee's diagnosis.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 bevacizumab and doxorubicin. Our reviewer says that the requested combination of chemotherapy agents is not medically necessary. Our physician reviewer found based on medical literature and National Comprehensive Cancer Network guidelines, either drug can be approved as a single agent but the combination therapy is approved for ovarian cancer only. The enrollee has a diagnosis of endometrial carcinoma.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of bevacizumab and doxorubicin have not been met. Therefore, we decided that the Plan does not have to pre-approve bevacizumab and doxorubicin (Q2050, Q5118).
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 an IRF admission is medically necessary for full recovery. The Plan denied your request. The Plan says the enrollee does not meet functional or medical necessity criteria for admission to IRF.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.

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 the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for seizures. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for a intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this enrollee 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 inpatient rehabilitation facility (IRF) admission and 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 with hypoxic respiratory failure due to aspiration pneumonia.  The enrollee is clinically 
improving.  The enrollee continues to receive acute care services, and these have not been denied.  The medical 
record does not indicate that the enrollee requires services that she is not currently receiving but that would be 
available at the LTACH facility.  The elements of the coverage rules are not satisfied.  The requested service 
cannot be recommended. 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 a cervical spine MRI and a thoracic spine MRI to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve a cervical spine MRI and a thoracic spine MRI to be provided by an OON provider. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are neither emergent nor urgent to seek out-of-network care. The Plan says there are in-network providers available to the enrollee that can provide the services being requested.

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 a cervical spine MRI and a thoracic spine MRI to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the collection of a blood sample from an implanted device provided on January 20, 2021.

You asked the Plan to waive the copayment for the collection of a blood sample from an implanted device. You say that you disagree with the charges. The Plan denied your request. The Plan says the claims were processed correctly, and you are being charged the correct amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 copayment for outpatient surgery, including services provided at hospital outpatient facilities.

You received the collection of a blood sample at an outpatient hospital facility on January 20, 2021. The collection of a blood sample is considered an outpatient surgical procedure. Therefore, you are responsible to pay the allowed amount of $110.73, which is less than the $250 copayment. 

You have been asked to pay $110.73 for the collection of a blood sample from an implanted device. The collection of a blood sample from an implanted device falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the collection of a blood sample from an implanted device provided on January 20, 2021.
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.