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

We decided that the Plan does not have to pay for the respiratory viral panel rendered on November 17, 2020.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the testing is not covered.

The Plan must follow Medicare rules. The rules say that tests that include more than 5 viral pathogens are non-covered.

We looked at the file and Medicare rules. The file shows that the testing at issue was a respiratory viral panel of six or more pathogens. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the respiratory viral panel rendered on November 17, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approve the acute inpatient hospital care.

You asked the Plan to pre-approve acute inpatient hospital care. You say that the enrollee clearly meets the inpatient criteria for coverage. You say that medically appropriate and quality care was provided to the enrollee. The Plan denied your request. The Plan says that the records provided do not demonstrate the medical necessity of inpatient hospital services.

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 pre-approve 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 transferred to the hospital after a fall and associated left hip fracture. She had two episodes of ventricular tachycardia. She was started on amiodarone drip and placed in the CCU. She was also started on antibiotics as she was found to be febrile. Based on the records, the enrollee needed close telemetry monitoring for the runs of V-tach and required cardiac workup and hip surgery which was expected to cross 2 midnights of hospital care based on the severity and complexity of the patient's 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 acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pre-approve the acute inpatient hospital care.

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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide routine transportation to and from your doctor's office.
You asked the Plan to provide routine transportation. You say that you need transportation to your doctor appointment following knee surgery. The Plan denied your request. The Plan says routine transportation is not covered.
The Plan must follow Medicare rules. Medicare does not cover transport in a vehicle that is not an ambulance. The Plan follows the same rule.
We looked at your request, the records in the case file, and the rules. The records do not show you were discharged from a hospital. Based on this information, we decided that the Medicare rules for coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to provide routine transportation to and from your doctor's office.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 10 additional physical therapy visits.

You asked the Plan to pre-approve the additional physical therapy visits. You say that you have sciatica nerve pain and fibromyalgia that causes muscle spasms. You say that, at times, they have to slow down your movements and other times they have to stop completely. You say that this slows down your progress and makes it harder for you to recover and make improvements. You say that you really need the additional visits requested to be able to bend and have the movement you need for normal mobility. You say that you do home exercises but that you cannot get to the point where you need to be. You say that you have been making progress but that it is just slower than expected. The Plan denied your request. The Plan says the enrollee does not meet the guidelines to show that there is a medical reason the enrollee needs additional physical therapy.

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 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 the additional physical therapy visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the additional requested therapy is not generally accepted as specific and effective therapy for the enrollee's condition beyond what was approved by the health plan. The enrollee has had prior extensive therapy and the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or by or under the supervision of a therapist. The enrollee has been provided adequate therapy sessions to be versed in a home exercise program. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration.

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 additional physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 10 additional physical therapy visits.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an upper gastrointestinal endoscopy and visualization
(esophagogastroduodenoscopy).
You asked the Plan to pre-approve an upper gastrointestinal endoscopy and visualization
(esophagogastroduodenoscopy). You say that the requested upper gastrointestinal endoscopy and visualization
(esophagogastroduodenoscopy) is medically necessary. The Plan denied your request. The Plan says the
enrollee does not meet criteria for upper gastrointestinal endoscopy and visualization
(esophagogastroduodenoscopy).
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 an upper gastrointestinal endoscopy and
visualization (esophagogastroduodenoscopy). Our reviewer says that the enrollee does not meet criteria for
upper gastrointestinal endoscopy and visualization (esophagogastroduodenoscopy). Our physician reviewer
found the enrollee complains of feeling: "very uncomfortable, unable to eat, very sick." The provider attests in
his 6/10/2021 appeal letter that the member has "abdominal pain, worse with meals, onset several weeks ago,
with change of bowel habits." The enrollee attributes these symptoms to start of Trulicity. Of note, at her initial
office visit on 6/7/2021, abdominal exam was documented as normal, and no red flags were listed. The
provider did not initiate an empiric trial of acid suppression therapy, order laboratory studies, nor order
abdominal ultrasound. Instead, EGD was advised.
Coverage criteria, based on available documentation that was supplied and reviewed, has not been 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 an upper gastrointestinal endoscopy and visualization
(esophagogastroduodenoscopy) have not been met. Therefore, we decided that the Plan does not have to preapprove
an upper gastrointestinal endoscopy and visualization (esophagogastroduodenoscopy).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy services rendered on July 2, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 97164 is not supported.
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 97164 is Physical therapy re-evaluation of established plan of care, high complexity, typical time with patient 20 minutes.
We find that CPT code 97164 is not supported in the medical record. Specifically, the file shows that the services were performed in the home setting and there is a more appropriate code for these services. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the physical therapy services rendered on July 2, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of Intron A with Bacillus Calmette-Guerin (BCG).
You asked the Plan to pre-approve Intron A and BCG. You say that the enrollee requires this treatment. The
Plan denied your request. The Plan says the denial of authorization for these drugs is correct, because this
combination is not Food & Drug Administration (FDA) approved nor supported by drug compendia 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 Intron A and BCG. Our reviewer says
that the enrollee does not meet the Medicare criteria for the requested use of Intron A and BCG. Our physician
reviewer found these drugs are not Food & Drug Administration (FDA) approved for the enrollee's diagnosis.
This use is not supported by one of the major drug compendia or by clinical research that appears in a
Medicare-approved medical journal. This combination of Intron A and BCG has not been shown to improve
outcomes compared to BCG alone.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Intron A and BCG have not been met. Therefore, we decided that the Plan does
not have to pre-approve use of Intron A with Bacillus Calmette-Guerin (BCG).
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 enrollee needs LTACH services. The
Plan denied your request. The Plan says the enrollee's medical needs are being met in the current acute setting.
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 review has determined that 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 she is
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 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 the LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on
February 27, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not
approved in advance.

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 for the services provided by an out-of-network provider on February 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for therapeutic continuous glucose monitor and supplies
provided January 11, 2021.

You asked the Plan to pay for therapeutic continuous glucose monitor and supplies. You say that you would
like this claim reprocessed for medical necessity. The Plan denied your request. The Plan says the claim is
missing required documentation.

The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a
physician order and proof of delivery.

The record does not contain a valid proof of delivery for the supplies provided in this case. Review of the file shows that the proof of delivery did not include an itemize order form or invoice to indicate the specific supplies; therefore, the billed supply code cannot be verified. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for therapeutic continuous glucose monitor and supplies provided January 11, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Myocardial perfusion imaging.

You asked the Plan to pre-approve Myocardial perfusion imaging, tomographic (SPECT) (including attenuation correction, qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); multiple studies, at rest and/or stress (exercise or pharmacologic) and/or redistribution and/or rest reinjection (78452). You say that the enrollee needs Myocardial perfusion imaging. The Plan denied your request. The Plan says the enrollee's stress test results were normal.

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 Myocardial perfusion imaging, tomographic (SPECT) (including attenuation correction, qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); multiple studies, at rest and/or stress (exercise or pharmacologic) and/or redistribution and/or rest reinjection (78452). Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the medical records provided do not document any of the indications enumerated in the local coverage determination. The elements of the coverage rule 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 Myocardial perfusion imaging, tomographic (SPECT) (including attenuation correction, qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); multiple studies, at rest and/or stress (exercise or pharmacologic) and/or redistribution and/or rest reinjection (78452) have not been met. Therefore, we decided that the Plan does not have to pre-approve Myocardial perfusion imaging.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Supartz (J7321).

You asked the Plan to pre-approve Supartz. You say that the enrollee has failed to respond to non-steroidal
anti-inflammatory drugs (NSAIDs) and steroid injection. The Plan denied your request. The Plan says the
information submitted does not meet the Plan's medical necessity guidelines for coverage.

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 Supartz. Our reviewer says that Supartz
is not shown to be currently medically necessary and reasonable. Our physician reviewer found the enrollee is
noted to have left knee osteoarthritis. A request has been made for Supartz, a hyaluronic acid injection, to treat
the osteoarthritis. The Plan requires that other forms of hyaluronic acid injections be used. Our reviewer found
that there is no evidence that the enrollee is allergic to or intolerant of these other forms of hyaluronic acid.
There is no evidence that the enrollee has tried and not responded to these other forms of hyaluronic acid
injections. Our physician reviewer also found that there is no documentation as to why these other forms of
hyaluronic acid would not be expected to be safe and effective 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 Supartz have not been met. Therefore, we decided that the Plan does not have to
pre-approve Supartz (J7321).
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 enrollee needs IRF care. The Plan denied your request. The Plan says the enrollee's care can be met at an alternate level of 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 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 there are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The patient does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that this patient 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 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 following cardiac arrest. The enrollee is ventilator dependent with severe neurological
injury. The enrollee is not clinically stable. The enrollee continues to receive acute critical care services that
have not been denied. The medical records provided do not indicate that the enrollee requires acute care
services that she is not currently receiving that would be available at the LTACH. 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 LTACH services.