Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean outpatient surgery to be provided by an out of network (OON) provider.You asked the Plan to pre-approvean outpatient surgery. You say that you would like approval for these services to be provided out-of-network.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 thePlan to pre-approve these items/services.Therefore, we decided that the Plan does not have to pre-approvean outpatient surgery to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider on August 3, 2020.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the services were not authorized.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 pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services.Therefore, we decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider on August 3, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean advanced knee and foot for a prosthetic device.You asked the Plan to pre-approvethe requested items. The Plan denied your request. The Plan says the enrollee relies on crutches and a cane for ambulation.The Plan follows Medicare rules. Medicare rules say that lower limb prostheses are only covered under certain medical indications. 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 requested items. Our physician reviewer found that the requested advanced foot/knee exceedsthe enrollee'smedical need.The supporting physical therapy progress notesindicate that he has crutches and cane. The records do not support that he is a K3 ambulator with vocational, therapeutic, or exercise activity that demands prosthetic utilization beyond simple locomotion. Therefore, the requested advanced foot and knee are 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 requested items have not been met.Therefore, we decided that the Plan does not have to pre-approvean advanced knee and foot for a prosthetic device.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forthe acute inpatient hospital care provided August 5, 2020, to August 6, 2020.You asked the Plan to pay foracute inpatient hospital care. You say that the care provided was medically necessary.The Plan denied your request. The Plan says inpatient care was not medically necessary and care could have been provided at observationlevel.The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the review indicates that the enrollee was a then, 64 year-old-male who presented to the emergency department on August 5, 2020, with 3 days of sharp chest pain lasting about 5 seconds but associated with dyspnea, palpitation, diaphoresis, nausea, not with fever, chills, cough, or vomiting. The review has determined that the record did not show that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier ED and/or observation care) would span two midnights.
We looked at this physician's review, the file,and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met.Therefore, we decided that the Plan does not have to pay forthe acute inpatient hospital care provided August 5, 2020, to August 6, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.The Plan must 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 reviewthe 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 enrollee does not meet criteria for IRF admission. 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 enrollee was admitted for respiratory failure and COVID-19 pneumonia. Medical conditions are stable. There are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs.The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy,in an intensive rehabilitation therapy program. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that LTACH Admission is medically necessary.The Plan denied your request. The Plan says the enrollee can receive same services at the current level of 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 documentation doesnot support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no required medical services identified that are available at the LTACH, that are not available at the current 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-approvelong term acute care hospital (LTACH) services
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that the enrollee has stabilized and is ready for transfer to an admission to an LTACH.The Plan denied your request. The Plan says rules for LTACH care have not been 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 the enrollee has a history of diabetes, hypertension and sleep apnea, and underwent cervical fusion surgery on January 8, 2021. The enrollee sustained a cardiac arrest, and intubation was required. The enrollee is receiving acute hospital care, and acute care services have not been denied. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving 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 the LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approvestem cell therapy.You asked the Plan to pre-approvestem cell therapy. You say that the requested stem cell therapy is medically necessary.The Plan denied your request. The Plan says the requested stem cell therapy 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 stem cell therapy. Our reviewer says that the requested stem cell therapy is not medically necessary. Our physician reviewer found this enrollee presents with a history of chronic left knee pain. Clinical exam findings are reported consistent with recent imaging evidence of decreased joint space in the medial and lateral compartments.  He has failed to improve despite prior non-operative treatment including activity modification, medications, steroid injections, viscosupplementation, and physical therapy. He is reportedly trying to avoid a total knee replacement. Under consideration is a request for amniotic stem cell injections for his left knee. Current evidence-based medical peer-reviewed literature indicate that stem cell therapy remains investigational for the treatment of knee osteoarthritis and knee cartilage regeneration. Therefore, the request for stem cell therapy would not be considered medically reasonable and necessary at this time as the safety and effectiveness have not been fully established.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of stem cell therapy have not been met.Therefore, we decided that the Plan does not have to pre-approvestem cell therapy.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Orencia for the enrollee. 
 
You asked the Plan to pre-approve Orencia. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the member has not tried and failed the preferred step therapy drug. 
 
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 Orencia. Our reviewer says that 
Orencia is not medically reasonable and necessary for the enrollee in this case. The documentation stated that 
the patient did not try and fail Stelara. Stelara would not likely be less effective or have more adverse side 
effects than the requested Orencia medication as these are each in the same class of medication and have been 
shown to have essentially equivalent risk and effectiveness. Our physician reviewer found that the enrollee's 
condition does not meet step therapy criteria for Orencia. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Orencia have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Orencia for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approveVyvanse 30mg Capsule.You asked the Plan to pre-approvethe medication. You say that the medication is necessary.The Plan denied your request. The Plan says the requested drug is intended for patient "self-administration."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-approveVyvanse 30mg Capsule.Benefits for the medicationmay be available under Medicare Part D.Contactthe 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 Plandoes not haveto pre-approvea wheelchair tie down kit.You asked the Planto pre-approvethe kit. You say that this is medically necessary.The Plandenied your request. The Plansaysan option/accessory that is beneficial primarily in allowing the enrollee to perform leisure or recreational activities outside of the home is non-covered.The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home.Therefore, we decided that the Plandoes not haveto pre-approvea wheelchair tie down kit.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services coded 81479, 81225, 81230, 81231, 81291, and 81380 provided on April 23, 2020.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the documentation does not support the codes 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. We find that CPT codes 81479, 81225, 81230, 81231, 81291, and 81380 are not supported in the medical record. Specifically, the place of service on the CMS-1500 form line 24B must reflect the location of the patient when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, place of service 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting place of service 11. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services coded 81479, 81225, 81230, 81231, 81291, and 81380 provided on April 23, 2020.
Appeal type: Testing
Decision: Partially Favorable

We decided that the Plan has to pre-approve the requested services. We decided that the Plan does not have to pre-approve .
You asked the Plan to pre-approve the requested services. The Plan says that there is a lack of electrocardiogram documentation of atrial fibrillation.
We decided that the Plan has to pre-approve the requested cardiac ablation services.
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 ablations services. Our physician reviewer found that the enrollee has ischemic heart disease, carotid artery disease and paroxysmal atrial fibrillation/flutter (PAF). He is symptomatic with the atrial fibrillation (AF), which has become more frequent of late. He is very active with symptomatic episodes of paroxysmal atrial fibrillation noted by history, and for which he has been to the ED. In addition, he had an ambulatory monitor which revealed a 3% AF burden, which is included in the provided medical records. Atrial fibrillation ablation in active patients with highly symptomatic PAF is reasonable, appropriate and medically necessary as an alternative to lifelong anti-arrhythmic therapy.
There is expert opinion, society guidelines and some randomized studies to support this approach in well selected patients with this condition. The medical record documents the AF history and the rhythm is noted on the enclosed ambulatory monitor tracings provided. Therefore, the requested ablation services are medically reasonable and necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage have been met. Therefore, we decided that the Plan has to pre-approve the requested cardiac ablation services.
We also decided that the Plan does not have to pre-approve an in-network exception.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that if you use an out-of-network provider, your share of the costs for your covered services may be higher.
The requested provider in this case is not a network provider with the Plan. The enrollee has out of network benefits. If the enrollee uses an out-of-network provider, the share of the costs for covered services may be higher. We found no exception which would require the Plan to provide an in-network exception for out of network benefits. Therefore, we decided that the Plan does not have to pre-approve an in-network exception.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forcontinuous positive airway pressure (CPAP) supplies (A7032, A7037, A7038, A7034, A7035, A7039, A7036) provided from February 28, 2020, to July 30, 2020.You asked the Plan to waive the coinsurance forCPAP supplies. You say that you should not be charged for these items because the enrollee uses a different supplier now.The Plan denied your request. The Plan says these items processed 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 20% coinsurance for durable medical equipment and related supplies. You have been asked to pay a 20% coinsurance of $147.79 for CPAP supplies ($738.95 total allowed amount x 20% = $147.79). 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 coinsurance forcontinuous positive airway pressure (CPAP) supplies (A7032, A7037, A7038, A7034,A7035, A7039, A7036) provided from February 28, 2020, to July 30, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approvehome health aide services.You asked the Plan to pre-approveaide services. The Plan denied your request. The Plan says there are no skilled services in the home.The Plan must follow Medicare rules. The rules say that THE services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. 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 aide services. Our physician reviewer found that you are apparently newly bedbound. An evaluation of same is not documented. Home health aide services for bathing have been ordered. There is no evidence that you arereceiving skilled home nursing or skilled home therapy. As such, the requested services are not shown to be medically necessary or reasonable.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of aide services have not been met.Therefore, we decided that the Plan does not have to pre-approvehome health aide services
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Bunionectomy (CPT Code(s): 28291, 28285) to be 
performed at an out-of-network facility. 
 
You asked the Plan to pre-approve the services. You say that the surgery is necessary. The Plan denied your 
request. The Plan says the service can be approved if performed by an 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 
Bunionectomy (CPT Code(s): 28291, 28285) to be performed at an out-of-network facility.