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

We decided that the Plan does not have to pre-approve Prostate Artery Embolization (PAE).
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The
Plan denied your request. The Plan says that the clinical value and effectiveness of PAE has not been
demonstrated in the peer-reviewed literature.
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 requested services are not considered medically reasonable and necessary in this case. Prostatic arterial
embolization (PAE) is considered an experimental technique to treat symptomatic benign prostatic hyperplasia
(BPH). Very limited studies have demonstrated possible short-term safety and efficacy. Our physician reviewer
found that your condition does not meet criteria for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve Prostate Artery Embolization (PAE).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services (88120) provided on April 7, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not a covered
screening test.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed in the Medicare rules section, are not covered.

The testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this
testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the lab
services (88120) provided on April 7, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Freestyle Lite diabetic testing supply kit.
You asked the Plan to pre-approve Freestyle Lite supplies. You say that you want to continue using the brand
of supplies that you already have. The Plan denied your request. The Plan says the denial of authorization for
these supplies is correct, because the preferred brands of supplies are Ascensia or LifeScan products and the
records do not show that you have failed with these products or have a reason that you cannot use these
preferred brands.
The Plan must follow Medicare rules. Medicare rules say that plans may limit coverage to certain brands,
items, and supplies as long as enrollees have access to all medically-necessary items. Your contract with the
Plan says that the Plan's preferred brands of diabetic testing supplies are Ascensia branded products and
LifeScan branded products.
We looked at the file and Medicare rules. The requested Freestyle Lite brand supplies are not among the Plan's
preferred brands for diabetic supplies. Please contact the Plan regarding coverage of preferred-brand products.
Based on this information, we decided that Medicare rules for coverage of Freestyle Lite supplies have not
been met. Therefore, we decided that the Plan does not have to pre-approve Freestyle Lite diabetic testing
supply kit.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Venofer.
You asked the Plan to pre-approve Venofer. You say that Venofer is medically necessary. The Plan denied
your request. The Plan says the clinical documentation provided shows that the enrollee has a diagnosis of iron
deficiency anemia without being confirmed on lab testing. The Plan says that the enrollee's lab results revealed
that the enrollee had a normal hemoglobin level without anemia.
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 Venofer. Our reviewer says that the
criteria for coverage have not been met. Our physician reviewer found the enrollee has a normal hemoglobin,
iron saturation, and elevated ferritin has no evidence of iron deficiency anemia. The enrollee's iron studies are
consistent with anemia of chronic inflammation. IV iron sucrose (such as with Venofer) is not reasonable or
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 Venofer have not been met. Therefore, we decided that the Plan does not have
to pre-approve Venofer.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that the enrollee's clinical condition, in addition to his
comorbidities, meets full IRF criteria. The Plan denied your request. The Plan says the enrollee does not meet
the Medicare criteria for admission to an IRF.
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 that the complexity of the enrollee's nursing, medical and rehabilitation needs does
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical
problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does
support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-
disciplinary rehabilitation program. There is not a reasonable expectation that the enrollee will be able to fully
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care after
February 17, 2022.
You asked the Plan to pre-approve SNF care. You say that you need additional time in the SNF to learn how to
take care of your wound better. 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 continued skilled nursing facility (SNF) care after February 17, 2022.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Prolia injections (CPT code J0897), for the enrollee.
You asked the Plan to pre-approve the medication. You say that it was decided to proceed with denosumab for
the enrollee's treatment of elevated fracture risk. The Plan denied your request. The Plan says the information
they received from the enrollee's provider did not include a diagnosis of osteoporosis, broken bones or previous
treatments.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the medication. Our physician reviewer
found based on the medical records provided and the Medicare-approved major drug compendia there is no
documentation that the requested use of Prolia injections (CPT code J0897) is Food and Drug Administration-
approved for the enrollee's diagnosis of osteopenia. The use of Prolia for osteopenia in a female (with a T score
of -0.1 in the lumbar spine and -1.9 in the femoral neck) is not supported by one of the major drug compendia
or by clinical research that appears in a CMS-approved medical journal. The use of Prolia for osteopenia in a
female (with a T score of -0.1 in the lumbar spine and -1.9 in the femoral neck) is not indicated supported or
recommended in any of the compendia. Based on the medical records provided the use of Prolia for osteopenia
in a female (with a T score of -0.1 in the lumbar spine and -1.9 in the femoral neck) does not meet Medicare
criteria for safe and effective and otherwise reasonable and necessary for this 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 the medication have not been met. Therefore, we decided that the Plan does not
have to pre-approve the Prolia injections (CPT code J0897), for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the BaroStim Neo System Implant (CPT code(s) 0266T
and C1825), for the enrollee.
You asked the Plan to pre-approve the services. You say that you are requesting implantation of a carotid sinus
baroreflex system for heart failure. The Plan denied your request. The Plan says a review of the current medical
literature indicates that this device is new and has undergone initial clinical trials. The Plan states further
investigation is still underway and the efficacy of baroreceptor activation in heart failure is still uncertain at this
time, and it is not recommended in current guidelines for the treatment of heart failure. The Plan states this
device is not the standard of medical practice for the treatment 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 the services. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found Baroreflex stimulation devices have been considered potential alternative treatments for
resistant hypertension and heart failure. The Barostim Neo system is an electronic pulse generator implanted
underneath the clavicle with a lead tunneled under the skin to the carotid sinus in the neck. The pulse generator
delivers electrical impulses, analogous to a cardiac pacemaker, to the baroreceptors of one of the carotid
arteries.
In August 2019 the Food and Drug Administration (FDA) approved the system for use in patients with
refractory heart failure who remain symptomatic despite treatment with guideline-directed medical therapy, are
New York Heart Association (NYHA) Class III, have an ejection fraction less than 35%, and are not candidates
for bi-ventricular pacing. This was based on a clinical study demonstrating improvement in normal daily
activities, distance walked, quality of life, and improved cardiac levels biomarker levels. There remains an
absence of randomized, blinded clinical studies examining long-term clinical outcomes establishing the value
of Barostim Neo in patient management. As a result, at this time the Barostim Neo system would not be
considered medically reasonable and necessary in this enrollee'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 the services have not been met. Therefore, we decided that the Plan does not
have to pre-approve the BaroStim Neo System Implant (CPT code(s) 0266T and C1825), for the enrollee.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for a second computed tomography (CT) scan provided to the enrollee on
August 3, 2021.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request.
The Plan says that the documentation submitted does not support two separate services were performed.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or
payment.
In this case, the definition of CPT 70450 is "Computed tomography, head or brain; without contrast material."
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. Our doctor found that the record provided is insufficient to support the denial of
coverage. Our reviewer says that in this case, the record indicates that the enrollee had a CT scan of the head on
August 3, 2021. The plan is indicating that this is a duplicate service of another claim but has not provided any
evidence regarding that fact. Therefore, we decided that the Plan has to pay for a second computed tomography
(CT) scan provided to the enrollee on August 3, 2021.
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 pay for an abdominal ultrasound (76775) provided on September 8,
2021.

You asked the Plan to pay for ultrasound 76775. You say that you are appealing with records to support this
level of service. The Plan denied your request. The Plan says the denial of payment for this service is correct,
because code 76775 has a procedure-to-procedure (PTP) edit value of 1 with code 93976 so is not separately
payable without an appropriate modifier.

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, we have confirmed that code 76775
is a column II code to column I code 93976. This claim has not been billed with an appropriate modifier to
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we
decided that the Plan does not have to pay for an abdominal ultrasound (76775) provided on September 8,
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 the requested IRF care is a medical necessity for the
enrollee. The Plan denied your request. The Plan says medical necessity rules for IRF care have not been met.
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 that the complexity of the enrollee's nursing, medical, and rehabilitation needs does
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational
therapy, and an intensive rehabilitation therapy program. While the enrollee has a need for physical and/or
occupational therapy, there is no documentation of a need for an intensive rehabilitation program. There is not
a reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive
rehabilitation therapy program provided in an IRF.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that the enrollee would benefit from IRF admission to improve overall functional mobility and safety prior to returning home. The Plan denied your request. The Plan says an intensive rehabilitation program 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 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 that the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve LTACH services. You say that the requested LTACH services are a medical necessity for the enrollee. The Plan denied your request. The Plan says medical necessity rules for LTACH services have not been met.

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 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 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 the enrollee 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 Plan.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that the enrollee will benefit from IRF care that cannot be accomplished at a lower level of care. The Plan denied your request. The Plan says under Medicare, the request 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 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 that the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.