Persius/hicric huggingface dataset:
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 the enrollee requires a multi-disciplinary approach for an extended period of time. The Plan denied your request. The Plan says based on Medicare guidelines, your request for approval of admission to an LTACH does 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 there is no documentation provided indicating medical necessity for LTACH services. 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, 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 long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable oxygen concentrator.

You asked the Plan to pre-approve a portable oxygen concentrator. You say that a portable oxygen concentrator is medically necessary as you lose your breath in the shower and in other circumstances. The Plan denied your request. The Plan says Medicare coverage criteria are not met.

The Plan must follow Medicare rules. The rules say that to qualify for portable oxygen, the patient must meet the criteria for home oxygen. The documentation must show that the patient is mobile in the home and would benefit from the use of portable oxygen in the home. Based on the medical records provided, your last oxygen saturation test indicated 95% saturation on room air. You were to have an appointment with a pulmonologist to address your concerns. However, based on the records within this appeal, you do not meet Medicare criteria for a portable oxygen concentrator. Therefore, we decided that the Plan does not have to pre-approve a portable oxygen concentrator.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa (J7323).

You asked the Plan to pre-approve Euflexxa. The Plan denied your request. The Plan says there is no physical examination or x-ray of the enrollee's left knee. The Plan also says that there is no mention of any other treatments done for the left knee.

The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 Euflexxa. Our reviewer says that the elements of the coverage criteria are not satisfied. Our physician reviewer found the record indicates that the enrollee has a diagnosis of rheumatoid arthritis of the knee. Our reviewer found that the Food and Drug Administration has not stated that the requested drug is indicated for the enrollee's condition. Our physician reviewer also found that the Medicare approved drug compendia do not contain a supportive citation for the use of the requested drug in the enrollee's clinical situation. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have to pre-approve Euflexxa (J7323).
Appeal type: DME/ Orthotics
Decision: Favorable

 We decided that the Plan has to pre-approve replacement of continuous positive airway pressure device (CPAP) coded as E0471, A736, A4604, A7030, A7039, A7028, A7029, A7031, A7032, A7033, A7038 E0562.  You asked the Plan to pre-approve replacement of CPAP. You say that the unit is over 5 years old. The knob and the humidifier is broken and the unit does not work per clinical notes from the ordering doctor. The Plan denied your request. The Plan says that the diagnosis does not support medical necessity.  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 replacement of CPAP. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found this enrollee has severe obstructive sleep apnea, treated with an adaptive-servo ventilation device.  The device is more than 5 years old and is nonfunctional.  According to the clinical note of 9/21/2021, the enrollee has not been using the device because it is nonfunctional.  No compliance reports are provided. The device is considered reasonable and medically necessary for this enrollee, if she is able to use it enough to meet minimum Medicare requirements.  A replacement device should be provided for a period of 3 months, to provide an opportunity for the enrollee to document compliance.  If the enrollee is unable to use the device for at least 4 hrs. a day for at least 70% of days during a 30-day interval, the device will be considered not 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 replacement of CPAP have been met. Therefore, we decided that the Plan has to pre-approve replacement of continuous positive airway pressure device (CPAP) coded as E0471, A736, A4604, A7030, A7039, A7028, A7029, A7031, A7032, A7033, A7038 E0562.   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: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an absolute quantitation of myocardial blood flow (AQMBF) positron emission tomography (PET) scan.

You asked the Plan to pre-approve an AQMBF PET scan. You say that the medical records provided support the need for the requested AQMBF PET scan. The Plan denied your request. The Plan says research studies have found a lack of evidence that routine use of the requested study would improve the outcome for the enrollee's type of condition.

The Plan must follow Medicare rules. Medicare rules say that PET scans 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 an AQMBF PET scan. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee has hypertension and morbid obesity and is undergoing evaluation by her physician for the complaint of dyspnea on exertion. Her physician ordered a cardiac PET scan to assess myocardial viability and blood flow as he felt that this study would be superior to a radionuclide stress test, as "Given her weight, the most appropriate stress study would be a pharmacologic PET scan as we would be less likely to get artifact or false readings." At issue is the medical appropriateness and necessity of a cardiac PET scan in the clinical evaluation of exertional dyspnea in a morbidly obese individual. Other modalities of stress testing have not been performed in this patient. Guidelines do not support the use of cardiac PET imaging in this role. As a result, at this time cardiac PET scanning would not be considered medically reasonable and necessary in this patient's clinical management. 

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 AQMBF PET scan have not been met. Therefore, we decided that the Plan does not have to pre-approve an absolute quantitation of myocardial blood flow (AQMBF) positron emission tomography (PET) scan.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pay for SNF services provided from May 20, 2021, through  June 18, 2021.  You asked the Plan to pay for SNF services. The Plan denied your request. The Plan says the SNF services were 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 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 pay for SNF services. Our reviewer says that daily skilled services are not medically necessary. Our physician reviewer found that from a nursing perspective, the enrollee received oral medications. The enrollee had stable vital signs. She tolerated a regular diet and thin liquids. Regarding rehabilitation services, the enrollee received physical therapy (PT) and occupational therapy (OT) evaluations in the SNF.  By the dates in question, the enrollee was independent with functional mobility and activities of daily living.  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 pay for SNF services provided from May 20, 2021, through June 18, 2021.
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 cannot take care of yourself in your current state and need inpatient rehabilitation to return to your prior independence. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. Your needs can be met in a less intensive setting, such as a skilled nursing facility.    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 with your current medical instability, you do not need to see a physician 3 times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical conditions. At your current functional level, you do not require intensive therapies, consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach to daily therapy. Your rehab needs can be addressed equally well in a skilled nursing facility once your medical condition improves. IRF admission is not medically appropriate.  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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia 60MG/ML injection (CPT code J0897), for the enrollee.

You asked the Plan to pre-approve the injection. You say that the injection is necessary. The Plan denied your request. The Plan says unable to establish if the preferred product zoledronic acid has been ineffective, not tolerated, or is contraindicated.

Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the injection. physician reviewer found the record indicates that the enrollee has age related osteoporosis without osteoporotic fracture. The requested medication is a new start. The provided records do not indicate that the enrollee has tried and failed the plan's preferred step one alternative. The record does not indicate that the enrollee has a contraindication to or would have an adverse effect from the plan's preferred step one alternative. The elements of the coverage criteria 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 injection have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia 60MG/ML injection (CPT code J0897), for the enrollee.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.  You asked the Plan to pre-approve SNF care. You say that if you are not placed into the SNF you will likely continue to deteriorate. The Plan denied your request. The Plan says the denial of authorization for SNF care is correct.  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 you do not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (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 skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for genetic testing (81455) provided September 2, 2020.  You asked the Plan to pay for the genetic testing. You say that the testing was medically necessary. The Plan denied your request. The Plan says this type of genetic testing is not FDA approved and is non-covered.  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 pay for the genetic testing.   Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the medical literature does not support that the entire genetic panel improves health outcomes and therefore the entire panel is considered 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 the genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing (81455) provided September 2, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve outpatient counseling to be rendered by the out-of-network (OON) provider.  You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request.  The Plan says there are in-network providers available to render the requested service. Additionally, the requested provider does not have a Medicare-eligible license to provide care.  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 Plan must follow Medicare rules. Medicare rules also say that no provider or supplier shall receive payment for services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare program. Additionally, Mental Health Counselors are not eligible to enroll in Medicare.  We looked at the file and Medicare rules. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the service at issue in this appeal. Additionally, the provider in this case is a Licensed Clinical Mental Health Counselor. The provider does not have a Medicare-eligible license to provide care. Medicare rules say that no provider or supplier shall receive payment for services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in Medicare. Therefore, we decided that the Plan does not have to pre-approve outpatient counseling to be rendered by the out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve 9 skilled nursing visits, 15 minutes each (G0299).  You asked the Plan to pre-approve 9 skilled nursing visits. You say that the services are medically necessary. The Plan denied your request. The Plan says the requested services are not medically necessary. The Plan also says that the enrollee and their caregivers have received education in the past.  The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.  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 9 skilled nursing visits. Our reviewer says that the requested 9 skilled nursing visits are not medically necessary. Our physician reviewer found the provided documentation shows the enrollee does not have documented skilled nursing needs. The reviewer found that the enrollee has access to caregivers around the clock. Therefore, the reviewer found that the requested skilled nursing visits 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 9 skilled nursing visits have not been met. Specifically, the file shows that the enrollee does not have a need for skilled services. Therefore, we decided that the Plan does not have to pre-approve 9 skilled nursing visits, 15 minutes each (G0299).
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the testing services coded as 95957, 95909, and 95886 provided on December 23, 2020.  You asked the Plan to pay for the testing services. You say that you would like these claims reprocessed based on the medical documentation provided. The Plan denied your request. The Plan says the documentation does not support the services as billed.   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 95886 is needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; complete, five or more muscles studied, innervated by three or more nerves or four or more spinal levels (List separately in addition to code for primary procedure).  The CPT Code Manual definition of code 95909 is nerve conduction studies; 5-6 studies.  The CPT Code Manual definition of code 95957 is digital analysis of electroencephalogram (EEG) (eg, for epileptic spike analysis).  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 testing services. Our reviewer says that the documentation does not support the services as billed. Our reviewer found the medical records provided do not include sufficient documentation to validate that a digital analysis of electroencephalogram (EEG) (eg. for epileptic spike analysis was performed on December 23, 2020.  The medical records indicate that real time electroencephalogram monitoring was performed, which in not covered under CPT code 95957, therefore CPT code 95957 cannot be verified.    Regarding CPT code 95909, the medical records indicate the use of pedicle screws which are not baseline nerve conduction studies and are not covered under CPT code 95909; therefore, CPT code 95909 cannot be verified.    For CPT code 95886, the medical records provided do not include sufficient documentation to validate that a Needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; complete 5 or more muscles studied, innervated by 3 or more nerves or four or more spinal levels, (List separately in addition to code for primary procedure) was performed on December 23, 2020. The medical records indicated the use of pedicle screws, which are not baseline nerve conduction studies and are not covered under CPT code 95909, therefore the nerve conduction study cannot be verified, which is necessary in order to meet the coding criteria for CPT 95886.  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 testing services have not been met. Therefore, we decided that the Plan does not have to pay for the testing services coded as 95957, 95909, and 95886 provided on December 23, 2020.