Persius/hicric huggingface dataset:
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa knee injections.
You asked the Plan to pre-approve the Euflexxa injections. You say that it is not good medical practice to switch to another agent when the enrollee has had positive results with Euflexxa in the past. The Plan denied your request. The Plan says since there is no evidence that the preferred drugs would be less effective, the step therapy criteria are not met.
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 the Euflexxa injections. Our reviewer says that the documentation does not support that the Euflexxa agent is medically reasonable and necessary given the step therapy rules. Our physician reviewer found the enrollee has knee pain with a diagnosis of osteoarthritis. She has failed conservative treatment. There is a statement that Euflexxa was used with benefit in 2011. However, the enrollee has not tried Monovisc or Orthovisc which are the preferred agents. The provided medical records do not indicate that the Plan's required drugs would likely be less effective and/or likely have adverse effects for the enrollee. 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 Euflexxa injections have not been met. Therefore, we decided that the Plan does not have to pre-approve Euflexxa knee injections.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on July 16, 2019 and billed under code G0483.

You asked the Plan to pay for code G0483. You say that this claim should be paid. The Plan denied your request. The Plan says Medicare coverage criteria for definitive drug testing were not met.

The Plan must follow Medicare rules. Medicare has specific documentation requirements for this type of testing. The physicians order and the medical records must specifically show how this testing will be used to treat illness or disease present in the enrollee at the time of service as opposed to this testing being done for screening purposes. Based on the records provided, the required Medicare criteria are not met. Therefore, we decided that the Plan does not have to pay for lab services provided to the enrollee on July 16, 2019 and billed under code G0483.
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. You say that the enrollee cannot stand for long periods of time and the chair is needed to assist the enrollee's caregiver. You say that the enrollee cannot care for and bath themselves. You say that the enrollee has almost fallen in the shower before. The Plan denied your request. The Plan says this item is not a covered benefit.
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: 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 services are not required, and there are no skilled needs.
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 the enrollee does not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment. The enrollee does not have a need for enteral feedings, complex daily wound care or other daily SNF level skilled nursing need. Her wound vac is not a daily SNF nursing service. This enrollee's functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist required to safely and effectively provide medically necessary and reasonable treatment only in a SNF. The enrollee does not require these skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis". As a practical matter, this enrollee does not require the necessary services on 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve vitrectomy (67042) to be provided by the out of network provider with the facility.
You asked the Plan to pre-approve the vitrectomy. You say that you do not feel the service can be safely provided in-network. The Plan denied your request. The Plan says there are in-network providers that are able to provide this service. Therefore, coverage criteria has not been met.
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 pre-approved care. 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 vitrectomy (67042) to be provided by the out of network provider with the facility.
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 the latest therapy notes from the SNF show that the enrollee would benefit from an interdisciplinary program with intensive therapy which is not available at the SNF. The Plan denied your request. The Plan says the enrollee does not meet the criteria for coverage of IRF care.
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 the enrollee is a female who was admitted to the hospital on 12/19/2019 for treatment of a hip fracture. Her stay was complicated by ongoing delirium and recurrent fevers. She was deemed medically stable for discharge to a skilled nursing facility on 01/09/2020. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that the patient required the intensity of an IRF stay with close physician or nursing supervision. The patient may benefit and participate in additional therapy of PT and OT but the patient does not require this on an intensive rehabilitation facility therapy program level 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the non-emergent ambulance transport provided on March 14, 2019.
You asked the Plan to pay for the non-emergent ambulance transport. You say that the non-emergent ambulance transport was medically necessary. The Plan denied your request. The Plan says the non-emergent ambulance transport was not medically necessary.
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. 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 the non-emergent ambulance transport. Our reviewer says that the non-emergent ambulance transport was not medically necessary. Our physician reviewer found the enrollee is a quadriplegic and required ambulance stretcher transportation for medical appointments. On 3/14/2019, the enrollee was transported from a physician appointment to her living facility. The documentation supports that other means of transport, such as a stretcher van would have been acceptable. The documentation does not support that the enrollee needed the expertise, services and lifesaving and life-sustaining equipment that only a fully-equipped ambulance could provide for safe transport on March 14, 2019. The documentation does not support that the ambulance transport on March 14, 2019 was medically reasonable and necessary for the enrollee. 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 non-emergent ambulance transport have not been met. Therefore, we decided that the Plan does not have to pay for the non-emergent ambulance transport provided on March 14, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an ultrasonic osteogenesis stimulator.
You asked the Plan to pre-approve these services. You say that your foot not healing is interfering with your
everyday life. The Plan denied your request. The Plan says that this is not medically necessary.
The Plan follows Medicare rules. Medicare rules say that an ultrasonic osteogenesis stimulator is covered if the
above criteria is met.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that
an ultrasonic osteogenesis stimulator is not medically reasonable and necessary in this case. You are noted to
be a diabetic with bilateral Charcot feet. Your Charcot disease is advanced, based on the fact that you already
exhibit arch collapse. Such fractures are considered progressive, chronic and neuropathic. They cannot be
treated in the same manner as an acute, isolated, non-diabetic fracture. While your fractures have been present
for more than ninety days, the use of a bone stimulator to treat them is considered experimental. Our physician
reviewer found that your condition does not meet Medicare criteria for an ultrasonic osteogenesis stimulator.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve an ultrasonic osteogenesis stimulator.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for services provided to the enrollee on February 18, 2019 and billed under codes 76641RT and 76641LT.
You asked the Plan to pay for codes 76641RT and 76641LT. You say that this claim should be paid. The Plan denied your request. The Plan says Medicare billing criteria are not met. Current Procedural Terminology (CPT) code 76641 RT (1 unit) remains not supported. The submitted medical records do not contain sufficient documentation to support the procedure code's level of complexity. The ultrasound report does not include detailed documentation of all the 4 quadrants and the retro areolar area of the breast inspected to support that the Ultrasound, breast, unilateral, real time with image documentation, including axilla when performed; complete was performed. The Plan states that there is a more appropriate code to bill for ultrasound, breast, unilateral, real time with image documentation, including axilla when performed; limited which is 76642. Therefore, the billed service cannot be verified. It is noted that multiple attempts were made to contact the provider for additional information.
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, for codes 76641RT and 76641 LT the billed service cannot be verified in the medical records submitted. The case records do indicate multiple attempts were made by the plan to contact the provider for additional information. Medicare rules for coverage of codes 76641RT and 76641LT have not been met. Therefore, we decided that the Plan does not have to pay for services provided to the enrollee on February 18, 2019 and billed under codes 76641RT and 76641LT.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6549.
You asked the Plan to pre-approve the compression stockings. You say that the compression stockings should be covered. The Plan denied your request. The Plan says gradient compression stockings A6549 are non-covered as a surgical benefit.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 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 A6549.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided to the enrollee from July 12, 2019 to August 10, 2019.
You asked the Plan to pay for the SNF services. The Plan denied your request. The Plan says that the enrollee's benefit is exhausted.
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care. The file shows that the enrollee received 100 days of SNF care during the benefit period from March 21, 2019 through May 8, 2019, May 17, 2019 through June 14, 2019 and June 20, 2019 through July 11, 2019. The Plan has covered 100 days of SNF care. Although the enrollee may still have needed skilled care, the Plan is not required to pay for more than 100 days of SNF coverage during this benefit period. The enrollee will be eligible for a new benefit period when the enrollee has not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided to the enrollee from July 12, 2019 to August 10, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from March 18, 2019 to March 25, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that the acute inpatient hospital care provided from March 18, 2019 to March 25, 2019 was medically necessary. The Plan denied your request. The Plan says that the acute inpatient hospital care provided from March 18, 2019 to March 25, 2019 was not medically necessary.
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 supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the enrollee was evaluated in the emergency department for evaluation of a seizure and reported suicidal thoughts. The enrollee reported to be non-compliant with medications and had an alcohol use disorder. He had a seizure in the emergency department on 3/11/19 and was admitted to the hospital for ongoing medical and mental health care. The enrollee was discharged and on 3/18/19 he returned to the emergency department with altered mental status, confusion and stuttering. The medical records provided indicate that the admitting physician expected the enrollee's admission to span two midnights. The enrollee's medical conditions were complex. He required evaluation by multiple specialists, close monitoring, and intense resource utilization. Inpatient care was reasonable and 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 acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from March 18, 2019 to March 25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve injections of the lower or sacral spine facet joint (64493, 64494).
You asked the Plan to pre-approve injections of the lower or sacral spine facet joint. You say that the requested injections will help with your pain. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that subsequent therapeutic injections at the same anatomic site are considered medically reasonable and necessary when the patient has had at least 50% pain relief for at least three (3) months from the prior therapeutic injection. 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 injections of the lower or sacral spine facet joint. Our reviewer says that the service is not medically necessary. Our physician reviewer found the provided medical records in this case do not document that you had at least 50% pain relief for at least three months from the prior therapeutic injection. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of injections of the lower or sacral spine facet joint have not been met. Therefore, we decided that the Plan does not have to pre-approve injections of the lower or sacral spine facet joint (64493, 64494).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Bystolic 5mg tablet.
You asked the Plan to pre-approve Bystolic 5mg tablet. You say that you need the requested medication. The Plan denied your request. The Plan says you have a medical only policy which does not include Part D prescription coverage, therefore the criteria for self-administered drug coverage has not been met.
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 Bystolic 5mg tablet.
Benefits for Bystolic 5mg tablet may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital discharge services provided to the enrollee from
June 17, 2019 to June 21, 2019 and billed under code 99239.
You asked the Plan to pay for code 99239. You say that this claim should be paid The Plan denied your
request. The Plan says Current Procedural Terminology (CPT) code 99239 (1 Unit) remains not supported. The
submitted discharge summary does not support hospital discharge day management of more than 30 minutes
was performed. A documented time duration of 31 minutes or more is required to support this code. Therefore,
the billed service cannot be verified. It is noted that multiple attempts were made to contact the provider for
additional information. We have insufficient documentation to corroborate the services so we can confirm
Medicare coverage has been met.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code and the medical record documentation must
support the services billed. In this case, code 99239 is a time-based code. The services provided do not support
the time requirement for this code. Therefore, we decided that the Plan does not have to pay for hospital
discharge services provided to the enrollee from June 17, 2019 to June 21, 2019 and billed under code 99239.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acupuncture services.
You asked the Plan to pre-approve the acupuncture services. You say that researched the acupuncturists that are in-network with the Plan and you didn't find anyone that you felt were credible or to your liking based on their credentials, training and years of experience. The Plan denied your request. The Plan says you must receive care from a 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 pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve acupuncture services.