Persius/hicric huggingface dataset:
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 a SNF admission. You say that there is no one to help you at home. The Plan denied your request. The Plan says your condition does not require skilled nursing care as inpatient.
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 a SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The beneficiary does not require skilled nursing or therapy services on a daily basis. This beneficiary 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 a SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a permanent infusion pump implant.
You asked the Plan to pre-approve infusion pump implant. You say that there is no evidence that there is a possibility of cross-talk between this device and the spinal cord stimulator, and the enrollee will attain maximum benefit from this implant in addition to the existing spinal cord stimulator. The Plan denied your request. The Plan says the enrollee already has a spinal cord stimulator; therefore, this second implanted programmable device is contraindicated.
The Plan follows Medicare rules. Medicare rules state that implantation of an infusion pump is contraindicated with the presence of other implanted programmable devices. 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 infusion pump implant. Our reviewer says that the enrollee does not meet the Medicare criteria for this infusion pump. Our physician reviewer found the enrollee has an implanted spinal cord stimulator; therefore, the requested infusion pump is contraindicated according to Medicare rules. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of infusion pump implant have not been met. Therefore, we decided that the Plan does not have to pre-approve a permanent infusion pump implant.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that transfer to an LTACH is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria for transfer are not met.
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 currently providing 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. Medicare coverage criteria for transfer are not met.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says this is 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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the device is experimental. More research is needed to show safety and efficacy of the 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 the device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the wheelchair and accessories to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the wheelchair and accessories. You say that you would like reconsideration because you fell and cannot go home without the wheelchair. The Plan denied your request. The Plan says you must use network providers to get medical services when there are network providers available.
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 wheelchair and accessories 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 this is medically necessary. The Plan
denied your request. The Plan says the enrollee is currently receiving appropriate care.
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 was admitted with acute encephalopathy, pneumonia, urinary tract
infection and heart failure with reduced ejection fraction. He is clinically improving. The record does not
indicate that the enrollee requires services that he is not currently receiving at the acute care facility that only
the LTACH facility could provide.
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: 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 would like reconsideration because the IRF
admission is medically necessary. The Plan denied your request. The Plan says you can safely receive your
needed care in another setting.
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 you do not require treatment by multiple therapies, including either physical therapy
or occupational therapy, and an intensive rehabilitation therapy program. Medically necessary services can be
provided in a different level of 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex Superion Interspinous device.
You asked the Plan to pre-approve the Vertiflex device. You say that you would like reconsideration because this procedure is medically necessary. The Plan denied your request. The Plan says the enrollee has multi-level lumbar disease and placement of Vertiflex at L2-L3 will not address the other levels.
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 the Vertiflex device is experimental and more research is needed to show its 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 Vertiflex device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex Superion Interspinous device.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care.
You asked the Plan to pre-approve the continuation of SNF care. You say that SNF care continues to be medically necessary. The Plan denied your request. The Plan says rules for SNF care are no longer met.
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 the continuation of SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled therapy service needs and no identifiable skilled nursing service needs. In addition, the beneficiary does not require skilled nursing or therapy services on a daily basis. Finally, this beneficiary 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 continuation of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xofigo.
You asked the Plan to pre-approve Xofigo. You say that the requested Xofigo is medically necessary. The Plan denied your request. The Plan says the requested Xofigo is not medically necessary.
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 Xofigo. Our reviewer says that the requested Xofigo is not medically necessary. Our physician reviewer found for this patient, Ra-223 would be considered medically necessary and standard of care in the setting of bone-only metastatic disease. I suspect he would benefit from Ra-223 even in the presence of visceral metastases, though such a treatment would not be based on category 1 evidence or consensus guidelines. The consultation notes and records describe "minimal visceral disease" though provide no evidence to support the treatment in this situation. In the absence of this information, the request 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 Xofigo have not been met. Therefore, we decided that the Plan does not have to pre-approve Xofigo.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).

You asked the Plan to pre-approve SNF care. You say that you need SNF care. The Plan denied your request. The Plan says rules for SNF care have not been met.

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 while there are identifiable skilled therapy service needs, there are no identifiable skilled nursing service needs. In addition, you do not require skilled nursing or therapy services on a daily basis. Finally, you do 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nutria-pharmaceutical injections and treatment with a Sanexas device reported on July 13, 2020.
You asked the Plan to pay for the nutria-pharmaceutical injections and treatment with a Sanexas device. You say that the treatment was medically necessary and should be covered. The Plan denied your request. The Plan says the record does not support that the procedures were performed as billed.
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 HCPCS/CPT Code Manual definition of code 97016 is application of blood vessel compression or decompression device to 1 or more areas. The HCPCS/CPT Code Manual definition of code 96372 is therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular. The HCPCS/CPT Code Manual definition of code J3490 is unclassified drug injection. The HCPCS/CPT Code Manual definition of code J1955 is injection, levocarnitine, per 1 gm. We find that CPT code 97016 is not supported in the medical record. Specifically, the record does not support that a blood vessel compression device was applied. The manufacturer of the Sanexas device describes it as an electric cell signaling energy wave device, which does not meet the criteria to report CPT code 97016. Payment for HCPCS/CPT codes 96372, J3490, and J1955 are not supported. Specifically, the record does not contain documentation of the dosage and type of drug administered in each injection, which is required by Medicare for these services to be reimbursed. Based on this information, we decided that Medicare rules for coverage of the nutria-pharmaceutical injections
and treatment with a Sanexas device have not been met. Therefore, we decided that the Plan does not have to pay for the nutria-pharmaceutical injections and treatment with a Sanexas device reported on July 13, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance services (A0428) provided on November 3, 2020.
You asked the Plan to waive the copayment for the ambulance services. You say that the ambulance services were the only way to accomplish your transfer according to COVID-19 protocols. The Plan denied your request. The Plan says you were charged this cost sharing correctly.
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 each ambulance trip. You had 1 ambulance trip. The Plan charged you $227.68 for these services. This means that you have been asked to pay less than or equal to 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 ambulance services (A0428) provided on November 3, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH is not medically necessary.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested admission to a LTACH is not medically necessary. Our physician reviewer found based on the limited documentation provided, the enrollee is currently undergoing treatment at an acute care hospital (ACH) for a left thigh abscess. The enrollee is not intubated/ventilated. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long-term care needs.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pay for a bypass graft (35661) and vascular embolization or occlusion (37242)
You asked the Plan to pay for a bypass graft and vascular embolization or occlusion. You say that these codes are supported in the records. The Plan denied your request. The Plan says that these procedures are not documented.
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 35661 is bypass graft, with other than vein; femoral-femoral. The definition of 37242 is vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the intervention; arterial, other than hemorrhage or tumor (eg, congenital or acquired arterial malformations, arteriovenous malformations, arteriovenous fistulas, aneurysms, pseudoaneurysms). 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 a bypass graft and vascular embolization or occlusion. Our reviewers says that these procedures are documented in the records. Our physician reviewer found the operative report includes documentation of CPT 35661, specifically, "We now inserted the 7F aptus sheath into the left 20F gore sheath and inserted a 20mm amplatzer plug into the distal aspect of the prior left illiac limb and deployed the plug." CPT 37242 is documented, specifically, "Our sheaths were withdrawn and the common femoral arteries clamped and arteriotomies extended and then the 8mm PTFE graft was passed in a subcutaneous fashion between the two groin incisions and then end to side anastomoses were completed with 5-0 prolene in a runnin fashion on each end from the graft to the common femoral arteries." 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 bypass graft and vascular embolization or occlusion have been met. Therefore, we decided that the Plan has to pay for a bypass graft (35661) and vascular embolization or occlusion (37242)
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.