Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CardioMEMs system for the enrollee.
You asked the Plan to pre-approve these services. You say that the enrollee urgently needs this device and procedure due to the member's worsening condition of heart failure. The Plan denied your request. The Plan says that implantable wireless pulmonary artery pressure monitoring is not medically necessary for management of heart failure.
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 these services. Our reviewer says that a CardioMEMs system is not medically reasonable and necessary for the enrollee in this case. In this circumstance therapy change based on data obtained from a CardioMEMs device has been demonstrated in only one trial to help reduce hospital readmission compared to standard medical therapy. Moreover, concerns have been raised about potential bias in this trial calling into question the results. Therefore, the efficacy of the CardioMEMS device is uncertain at this time according to leading authorities and not recommended in current guidelines for the treatment of heart failure. Our physician reviewer found that Medicare coverage criteria are not met since the device should still be considered experimental or investigational. 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 a CardioMEMs system for the enrollee.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy from an out of network (OON) provider.
You asked the Plan to pre-approve the out-of-network physical therapy services. You say that you were told this provider was in-network. The Plan denied your request. The Plan says Empower Physical Therapy is not contracted in the enrollee's network. The Plan says that the medically necessary physical therapy services can be supplied 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 physical therapy from an out of network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for somatosensory testing (95938) and a central motor evoked
potential study (95939) provided August 19, 2019.
You asked the Plan to pay for codes 95938 and 95939. You say that the services provided were medically
necessary. The Plan denied your request. The Plan says the procedure was not billed with a Medicare covered
diagnosis.
The Plan must follow Medicare rules. The rules state that Medicare has established limited coverage for codes
95938 and 95939. These codes will only be covered for the diagnosis codes listed in the Local Coverage
Article A56773.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of codes 95938 and 95939 have not been met. Specifically, the record shows that the claim was not
billed with one of the Medicare covered diagnosis codes. Therefore, we decided that the Plan does not have to
pay for somatosensory testing (95938) and a central motor evoked potential study (95939) provided August 19,
2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea thoracic epidural steroid injection.You asked the Plan to pre-approvethoracic epidural steroid injection. You say that your pain is increasing.The Plan denied your request. The Plan says the denial of authorization for this service is correct, because there is not enough evidence in support of this procedure for your condition.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 thoracic epidural steroid injection. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this procedure is still considered experimental/investigational since there are not sufficient studies proving its effectiveness.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of thoracic epidural steroid injection have not been met.Therefore, we decided that the Plan does not have to pre-approvea thoracic epidural steroid injection.
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 you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested admission is not medically necessary.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 you required moderate assistance with bed mobility, dressing, and walking 100 feet. You required minimal assistance with transfers. You required maximal assistance with toileting and bathing. You are currently medically stable. There is no evidence of complex medical issues that require monitoring by an inpatient physical medicine and rehabilitation physician three times per week or acute rehab nursing care. While you may benefit from continuing physical therapy and occupational therapy, there is no evidence of need for an intensive therapy program with therapy 3 hours per day with frequent physician oversight and an interdisciplinary approach to rehabilitation 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 carehave not been met.Therefore, we decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveskilled nursing facility (SNF) services.You asked the Plan to pre-approveSNF services. You say that this is medically necessary.The Plan denied your request. The Plan says that the enrollee's needs are custodial.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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for SNF 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 SNF services have not been met.Therefore, we decided that the Plan does not have to pre-approveskilled nursing facility (SNF) services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care.
You asked the Plan to pre-approve the continuation of skilled nursing facility (SNF) care. You say that the requested continuation of SNF care is medically necessary. The Plan denied your request. The Plan says the requested continuation of SNF care does not meet criteria.
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 continuation of skilled nursing facility (SNF) care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to SNF on 1/21/20 with primary diagnosis of severe sepsis with muscle weakness. From a nursing perspective, the enrollee received oral medications. The enrollee had stable vital signs. She used oxygen via nasal cannula. She had routine foley catheter care. Regarding rehabilitation services, the enrollee received physical therapy and occupational therapy in the SNF. By the dates in question, the enrollee was at a contact guard assist level with functional mobility including gait to 50 feet with a rolling walker. The enrollee required varying assist with activities of daily living. There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. This enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the continuation of skilled nursing facility (SNF) care have not been met. Therefore, we decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve repeat radiofrequency ablation services.
You asked the Plan to pre-approve the repeat radiofrequency ablation services. You say that the notes don't
show the enrollee had 80% or more improvement in pain from the last procedure because he never had the last
procedure done. The appointment was rescheduled for March 2, 2020. The Plan denied your request. The Plan
says the records do not show that the last procedure improved the enrollee's pain and ability to do daily
activities by at least 50% for 6 months or more. The Plan says that the requested repeat procedure is not
supported without this pain relief.
The Plan follows Medicare rules. Medicare rules say that repeat radiofrequency ablation services are 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 the repeat radiofrequency ablation
services. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the
enrollee had a prior radiofrequency ablation of the lumbar facets. Our physician reviewer also found that the
enrollee had an epidural steroid injection which provided brief relief. The progress notes do not clearly
document the duration and degree of relief from the prior radiofrequency ablation services. The requested
procedure has not been shown to be medically necessary at this time.
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 repeat radiofrequency ablation services have not been met. Therefore, we
decided that the Plan does not have to pre-approve repeat radiofrequency ablation services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 50mcg/hr Fentanyl.You asked the Plan to pre-approve Fentanyl. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says this medication does not fall under Part B coverage.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 50mcg/hr Fentanyl. Benefits for Fentanyl 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprove a pneumatic compression device (E0652).
You asked the Plan to preapprove a pneumatic compression device. You say that the enrollee requires the
device. The Plan denied your request. The Plan says the documentation did not support the 4-week trial using
the basic pump that Medicare requires.
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily,
multiple-hour home usage of the E0650 or E0651 is required.
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting,
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. Therefore, we decided that the Plan does not have to preapprove a pneumatic compression device (E0652).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services beyond February 9, 2020.
You asked the Plan to pre-approve these services. You say that you need more care. The Plan denied your request. The Plan says the continued services are not medically necessary.
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 these services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the submitted records show that you received oral and inhaled medications and had stable vital signs. You received physical, occupational, and speech therapy in the SNF and need assistance with bed mobility and transfers with a wheeled walker. You are able to walk five feet with minimal assistance. You need varied assistance with activities of daily living. You have no skilled nursing or skilled therapy needs. You do not need skilled nursing or skilled therapy on a daily basis. As a practical matter, you do not require the necessary services on an inpatient basis at the SNF level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services beyond February 9, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the left and right shoulders for enrollee.You asked the Plan to pre-approve these services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are not medically necessary.The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the records contain no documentation showing objective abnormal left or right shoulder findings to support a need for imaging. Prior x-ray results of the left and right shoulder areas was not completed. There is no sufficient documentation to support that the MRIs are 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 these services have not been met.Therefore, we decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the left and right shoulders for enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvestab phlebectomy.You asked the Plan to pre-approvestab phlebectomy. You say that you are appealing with medical records.The Plan denied your request. The Plan says the denial of authorization for this service is correct, because stab phlebectomy is not medically necessary for the enrollee at this time.The Plan follows Medicare rules. Medicare rules say that stab phlebectomy procedures are only covered when the enrollee meets certain specific criteria and has failed conservative treatment.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 stab phlebectomy. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested stab phlebectomy. Our physician reviewer found the Plan requires that for this stab phlebectomy to be covered, the truncal venous reflux must have already been treated and that the enrollee continues to have lifestyle limiting symptoms despite conservative treatments. There is not a compelling reason to overturn the Plan's decision. The enrollee has documented evidence of greater saphenous vein reflux however the Plan has already approved coverage for ablation.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of stab phlebectomy have not been met.Therefore, we decided that the Plan does not have to pre-approvestab phlebectomy.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveinsertion of an interspinous and/or interlaminar deviceYou asked the Planto pre-approvethe services. You say that this is medically necessary.The Plandenied your request. The Plansaysmedical studies haven't proven that this device is helpful for treatment of your health problem.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 todetermine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the requested device is not considered medically reasonable and necessary in this case. Our physician reviewer found this device remains experimental, and more research is needed.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 services have not been met.Therefore, we decided that the Plandoes not haveto pre-approveinsertion of an interspinous and/or interlaminar device
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on August 23, 2019.
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 there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician. We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 drug testing rendered on August 23, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve routine transportation beyond 75miles.You asked the Plan to pre-approvethese services. You say that you need transportation to medical appointments.The Plan denied your request. The Plan says you have exhausted the benefit limit.Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 60 one-way trips per year and each trip cannot exceed 75 miles.We looked at your request, the records in the case file, and the rules. You are requesting transportation for a one-way trip of more than 75 miles. Therefore, we decided that the Plan does not have to pre-approveroutine transportation beyond 75 miles.