Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the acute inpatient hospital care, for the enrollee.  

You asked the Plan to pre-approve acute inpatient hospital care. You say that the enrollee is having trouble breathing and chest pains. The Plan denied your request. The Plan says the stay 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 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 does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the record indicates that the enrollee, who is on chronic hemodialysis, presented to the emergency room with dyspnea and pleuritic chest pain and was admitted for acute on chronic hypoxic respiratory failure in the setting of recent Coronavirus (COVID-19) infection.    

The record is sufficient to determine that the treating physician has a reasonable expectation of a length of stay spanning two (2) or more midnights. The elements of the coverage rule are satisfied. The requested service is 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 acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pre-approve the acute inpatient hospital care, for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.  

You asked the Plan to pre-approve the LTACH services. You say that LTACH is the appropriate level of care for this enrollee. The Plan denied your request. The Plan says based on Medicare guidelines, the requested LTACH services do not meet the requirements for approval.  

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 that in this case the enrollee has had a complicated hospital course. The record indicates that the enrollee is improving but still requires acute care services. The enrollee continues to receive acute care services, and these have not been denied. The medical record does not indicate that the enrollee requires services that she is not currently receiving but that would be available at the LTACH facility. 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 long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the home ventilator.

You asked the Plan to pre-approve the home ventilator. You say that you would like reconsideration because without the use of the requested device, the enrollee faces serious life-threatening conditions and even death. The Plan denied your request. The Plan says the requested device is not medically necessary.

The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. 

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 home ventilator. Our reviewer says that the provided primary source documentation does not contain sufficient detailed information in the medical record to justify the treatment selected. Our physician reviewer found the enrollee could be treated with a BiPAP machine with average volume-assured pressure support capability. The record provided does not indicate that such a device was trailed and failed. The elements of the coverage criteria are not satisfied.

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 home ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve the home ventilator.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Orencia.

You asked the Plan to pre-approve Orencia. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug does not meet step therapy criteria.

Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Orencia. Our reviewer says that the documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer found the enrollee has rheumatoid arthritis. The enrollee has tried and failed treatment with methotrexate and leflunomide. The documentation does not support that the enrollee has tried and failed Remicade, infliximab, Inflectra, or Simponi Aria. The documentation does not support any indication that plan's required drug(s) 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 Orencia have not been met. Therefore, we decided that the Plan does not have to pre-approve Orencia.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a continued skilled nursing facility (SNF) stay.  

You asked the Plan to pre-approve the continued SNF stay. You say that the enrollee may have an infection and needs further medical treatment. You also say that the enrollee has several open wounds and is unable to clean and re-dress daily as instructed by the providers. The Plan denied your request. The Plan says the enrollee has improved in physical therapy, and they appear to be at their functional baseline. The Plan also says that the enrollee has reached their functional potential, and their needs can be met at a lower level of care.  

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 continued SNF stay. Our reviewer says that the enrollee does not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 continued SNF stay have not been met. Therefore, we decided that the Plan does not have to pre-approve a continued skilled nursing facility (SNF) stay.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the CGM receiver (CPT code K0554NU) and CGM supplies (CPT code K0553NU), for the enrollee.

You asked the Plan to pre-approve the CGM and supplies. You say that it is medically necessary based on type 2 diabetes mellitus with hyperglycemia. The Plan denied your request. The Plan says the Medicare rules have not been met.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan.

We looked at the file and Medicare rules. The documentation indicates that the enrollee is not insulin-treated with multiple (three or more) daily administrations of insulin or a continuous subcutaneous insulin infusion (CSII) pump; and the enrollee's insulin treatment regimen does not require frequent adjustment by the beneficiary on the basis of BGM or CGM testing results. Based on this information, we decided that Medicare rules for coverage of the CGM and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve the CGM receiver (CPT code K0554NU) and CGM supplies (CPT code K0553NU), for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a MyoPro orthotic device.  

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 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 the services are not medically necessary. Our physician reviewer found the records show that you had a stroke followed by a cervical spinal cord injury and upper extremity paralysis. The records do not support that the MyoPro is more safe and effective than standard treatments. The MyoPro is not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a MyoPro orthotic device.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the electronic analysis of an implanted neurostimulator pulse generator/transmitter (95972) provided on July 2, 2021.  You asked the Plan to pay for the electronic analysis of an implanted neurostimulator pulse generator/transmitter. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says an edit exists between CPT code 95972 and 63685.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.  We asked our coder 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 electronic analysis of an implanted neurostimulator pulse generator/transmitter. Our reviewer says that CPT code 95972 does not meet criteria for billing or reimbursement consideration. Our reviewer found the medical records provided does not include sufficient documentation to support CPT 95972 XE was performed at a separate encounter that CPT 63655 and 63685, also performed on July 2, 2021, therefore procedure 95972 XE is not eligible for separate reimbursement, as it is bundled with 63655 and 63685.  We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the electronic analysis of an implanted neurostimulator pulse generator/transmitter have not been met. Therefore, we decided that the Plan does not have to pay for the electronic analysis of an implanted neurostimulator pulse generator/transmitter (95972) provided on July 2, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve SNF care.  

You asked the Plan to pre-approve SNF care. You say that the enrollee has no body around to take care of them and their son is two hours away. You state the enrollee is unable to even go to the bathroom even with their walker. The Plan denied your request. The Plan says the stay is not medically necessary based on SNF criteria. The Plan states your request does not show that the enrollee has skilled nursing or therapy needs that need to be provided on a daily basis as an inpatient only status. The Plan states the services the enrollee requires can safely be received at a different setting, for example, home with home health, in residential care, or home with close follow-up with the enrollee's doctor.  

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a SNF 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Methadone.

You asked the Plan to pre-approve Methadone. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug is not a covered benefit.

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 Methadone.

Benefits for Methadone 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 pre-approve oral device/appliance for sleep apnea (CPT code E0486), for the enrollee.

You asked the Plan to pre-approve the oral device. You say that the enrollee sought treatment for obstructive sleep apnea with oral appliance therapy. The Plan denied your request. The Plan says there is no clinical evidence to support the medical necessity of this oral device/appliance or that the enrollee meets Medicare criteria for the device.

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 oral device. physician reviewer found a mandibular advancement device is considered not medically necessary because Medicare criteria are not met. This enrollee has mild obstructive sleep apnea (OSA), with apnea-hypopnea index (AHI) between 5 and 15. According to the medical documentation, the enrollee does not have excessive daytime sleepiness, impaired cognition, mood disorders, insomnia, hypertension, ischemic heart disease, or history of stroke. Therefore, the OSA is not severe enough to require treatment. The denial is upheld. 

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 oral device have not been met. Therefore, we decided that the Plan does not have to pre-approve oral device/appliance for sleep apnea (CPT code E0486), for the enrollee.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve continuation of SNF care from January 11, 2022, forward.  You asked the Plan to pre-approve SNF care. You say that you are not ready to be released due to you not being able to care for yourself. You state that you are needing a daily wound dressing, catheter care at least more than once a day if not more, physical therapy, occupational therapy, total assist with bathing, extensive assist with toileting, and extended assist with transfers. The Plan denied your request. The Plan says your request does not meet Medicare guidelines because there are no noted daily skilled complex nursing or therapy needs which would meet the guidelines for continued SNF services. The Plan states while you may benefit from continuing physical, occupational, and speech therapy, the records do not support the need for daily therapy on an inpatient basis.  The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs. You do not require skilled nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a SNF 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve continuation of SNF care from January 11, 2022, forward.
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 clearly exceeds the Centers
for Medicare & Medicaid Services (CMS) established defining criteria for an appropriate LTACH admission.
The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient acute care and does
not require transfer to an LTACH.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found the enrollee does not require services at the LTACH that are not available at the acute
care hospital where he is currently receiving care. Our reviewer found that 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. 
Our physician reviewer also found that the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an 
inpatient basis.

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: 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 you would like reconsideration because the documentation supports the medical necessity of the requested IRF care. The Plan denied your request. The Plan says you do not meet Medicare coverage criteria for the requested 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 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 based on the medical records provided the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Based on the medical records provided there is concern that you will not be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility due to your reported poor activity tolerance and pain level. Care at the skilled nursing facility level appears to be appropriate in this case.  

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.