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

We decided that the Plan has to pre-approve an angioplasty without stenting (37229).
You asked the Plan to pre-approve an angioplasty without stenting. You say that the requested service is
medically necessary. The Plan denied your request. The Plan says that angioplasty without stenting is
nationally non-covered under Medicare.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item
or service, then that item or service will be covered when it is medically necessary.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve an angioplasty without stenting. Our
reviewer says that the requested items/services are considered medically reasonable and necessary in this case.
Our physician reviewer found that the enrollee has lower extremity claudication and lower extremity vascular
disease and you are proposing angioplasty treatment, atherectomy, and possible stenting of the left lower
extremity vessels. The Plan is applying National Coverage Determination (NCD) criteria for the
cerebrovascular vessels and carotid arteries, which is an error. Percutaneous Transluminal Angioplasty (PTA)
is covered for atherosclerotic lesions of the lower extremity if the vessels cannot be stented for technical
reasons, which is not known until the procedure is performed. The Plan is applying the wrong NCD code and
the services requested are medically reasonable, appropriate, 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 of an angioplasty without stenting have been met. Therefore, we decided that the
Plan has to pre-approve an angioplasty without stenting (37229).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Savella for the enrollee.
You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your request. The Plan says that this is not covered under Part B.
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 Savella for the enrollee.
Benefits for this drug 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: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve high intensity focused ultrasound (HIFU).
You asked the Plan to pre-approve HIFU. You say that you would like the plan to reconsider their denial The Plan denied your request. The Plan says that the requested services are not medically necessary.
The Plan follows Medicare rules. Medicare rules say that HIFU is covered for certain 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 HIFU. Our reviewer says that the documentation supports that the requested services are medically reasonable and necessary. Our physician reviewer found the enrollee has T2b gleason 6 prostate cancer. The documentation supports that this request will be a first line therapy. Per National Comprehensive Cancer Network (NCCN) guidelines, 2.2021 prostate cancer page MS32, HIFU has a a radical treatment free survival of 89% at two years with 97% continence rate and 78% erectile preservation rate. Therefore, the enrollee meets criteria for the requested services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of HIFU have been met. Therefore, we decided that the Plan has to pre-approve high intensity focused ultrasound (HIFU).
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee's ongoing skilled therapy and nursing needs can be provided at a lower 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. The enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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 for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says the enrollee is not
able to tolerate an intensive therapy program.
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 physician reviewer found
that the enrollee was admitted to the acute hospital for surgical treatment of a hip fracture after a fall. Her
medical problems are stable. There are no complex nursing needs. There is not a reasonable expectation that
she will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in
an IRF. While the medical record supports a need for physical and/or occupational therapy, there is no
documented need for intensive rehabilitation services.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor.
You asked the Plan to pre-approve the requested monitor. You say that the monitor is necessary for you to
check your blood sugar levels. The Plan denied your request. The Plan says you are not taking insulin multiple
times per day.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based
on the blood glucose testing results.
We looked at the file and Medicare rules. The documentation does not indicates that you use insulin with at
least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose
testing results. Based on this information, we decided that Medicare rules for coverage of the requested monitor
have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose
monitor.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the office visits to be provided by an out-of-network provider.
You asked the Plan to pre-approve the office visits. You say that the only specialists that are open will not be in-network until May 1, 2021, and you need to be seen before that. The Plan denied your request. The Plan says there are in-network providers available in your area and this is not a gap issue. The Plan states there is no medical need shown as to why you cannot get these office visits from 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 the office visits to be provided by an out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the regadenoson injection and rubidium Rb-82 provided on November 2, 2020.
You asked the Plan to waive the coinsurance for the regadenoson injection and rubidium Rb-82. You say that you've had this same kind of test done many times and were never charged anything. You say that you would not have agreed to have this test if you had to pay such a large amount. The Plan denied your request. The Plan says the coinsurance applied 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 20% coinsurance for each Medicare-covered Part B drug and non-chemotherapy drugs to treat cancer from an in-network provider and 20% coinsurance for each Medicare-covered medical supply from an in-network provider. You have been asked to pay a total of $255.65 for the regadenoson injection and rubidium Rb-82.
Service
Allowed Amount
Coinsurance
Member Liability
Regadenoson Injection
$236.76
20%
$208.30
Rubidium Rb-82
$1,041.50
20%
$47.35
TOTAL:
$255.65
The regadenoson injection falls within the "Medicare Part B Prescription Drugs" benefit category. The rubidium Rb-82 falls within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the regadenoson injection and rubidium Rb-82 provided on November 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve right side arthrodesis of the sacroiliac joint.
You asked the Plan to pre-approve Arthrodesis, sacroiliac joint, percutaneous or minimally invasive (indirect visualization), with image guidance, includes obtaining bone graft when performed, and placement of transfixing device (27279). You say that you need this procedure because of your severe back and hip pain. The Plan denied your request. The Plan says there is no documentation of a positive Gaenslen's test or Distraction test which is required per Medicare rules.
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 Arthrodesis, sacroiliac joint, percutaneous or minimally invasive (indirect visualization), with image guidance, includes obtaining bone graft when performed, and placement of transfixing device (27279). Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found anterior pelvic compression test is positive. However, detailed documentation is not evident regarding at least 3 positive exam findings to suggest sacroiliac (SI) joint pathology. Documentation of a prior diagnostic right SI joint injection is not evident. Furthermore, multiple other plausible pain generators including at the lumbosacral spine are evident. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines. Therefore, the request for right-side arthrodesis, sacroiliac joint, percutaneous or minimally invasive is not medically reasonable or necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Arthrodesis, sacroiliac joint, percutaneous or minimally invasive (indirect visualization), with image guidance, includes obtaining bone graft when performed, and placement of transfixing device (27279) have not been met. Therefore, we decided that the Plan does not have to pre-approve right side arthrodesis of the sacroiliac joint.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from May 20, 2020 to May 27, 2020.
You asked the Plan to pay for acute inpatient hospital care. You say that it is your understanding that this denial is based on lack of medical necessity for inpatient level of care. You disagree with this decision. The Plan denied your request. The Plan says that coverage denied due to failure to follow the Plan's contractual notification requirements.
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 presented to the ED on 5/20/2020 after having a CVA after chemotherapy. She was evaluated and also had evidence of cholangitis and septic shock. She was discharged home 5/27/20 at hospice level of care. The record shows that at the time of inpatient admission the admitting physician reasonably expected that the enrollee'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 been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from May 20, 2020 to May 27, 2020.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee's ongoing skilled therapy and nursing needs can be provided at a lower 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. 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 patient was admitted for weakness, dizziness, and falls and was treated for worsening chronic kidney disease. The enrollee's medical problems are stable. 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. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care 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. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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 for the enrollee.
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 these services are medically necessary. The Plan
denied your request. The Plan says that your medical condition has improved and no longer requires the need
for Inpatient Rehabilitation or Long-Term Acute Care 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. The
complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay
with an interdisciplinary approach to rehabilitation care. You were admitted for pneumonia, respiratory failure,
renal failure and encephalopathy Your medical problems are stable. There are no complex nursing or
rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or
occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a
need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation
services. Medically necessary care can be provided in a different level of care. There is not a reasonable
expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy
program provided in an IRF. Our physician reviewer found that your condition does not meet Medicare criteria
for IRF 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an inpatient admission following an elective total shoulder arthroplasty.
You asked the Plan to pre-approve acute inpatient hospital care. You say that you are requesting review of denial of services. The Plan denied your request. The Plan says the requested hospital stay is not covered because it is not 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 looked at 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. The planned procedure listed under CPT Code 23472 is not listed on the CMS Inpatient Only List. The procedure is currently approved as an ambulatory procedure. There is no documentation provided to support the expectation that you will require than two (2) midnight stay. If you experience any peri- or post-operative complications, reconsideration for inpatient level of care can be performed on concurrent review with updated clinical information. Therefore, we decided that the Plan does not have to pre-approve an inpatient admission following an elective total shoulder arthroplasty.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing (80307, G0483) provided on June 18, 2020.
You asked the Plan to pay for drug testing. You say that these codes are supported. The Plan denied your request. The Plan says these services were billed with an incorrect POS.
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS). We looked at the file and Medicare rules. The services at issue were billed with POS 81 for an independent laboratory, but the records show that the sample was not taken in the laboratory. Based on this information, we decided that Medicare rules for coverage of drug testing have not been met. Therefore, we decided that the Plan does not have to pay for drug testing (80307, G0483) provided on June 18, 2020.