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

We decided that the Plan does not have to pre-approve compression stockings identified with code A6530.
You asked the Plan to pre-approve the compression stockings. You say that this will help reduce swelling. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are noncovered because they do not meet the statutory definition of a surgical dressing. Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6530
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve sedation services.  You asked the Plan to pre-approve sedation. The Plan denied your request. The Plan says the requested sedation is not medically necessary.  The Plan follows Medicare rules. Medicare rules say that documentation must clearly establish the need for such sedation.  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 sedation. Our physician reviewer found that the enrollee has a history of lumbar degenerative disc disease and left hip pain. An epidural injection under monitored anesthesia care (MAC) sedation was recommended.  When there is documentation by the proceduralist and/or anesthesiologist in the medical record that specific risk factors or significant medical conditions are present, MAC sedation is considered medically necessary. In this case, the documentation does not substantiate an appropriate clinical or psychological condition to warrant the requested service. The records do not clearly establish a need for MAC sedation for this enrollee's injections. Therefore, the requested monitored anesthesia care is not medically reasonable or necessary.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of sedation have not been met. Therefore, we decided that the Plan does not have to pre-approve sedation services.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a radiation oncology consultation visit to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve consultation visit. You say that the requested location is closer to the enrollee's home, and you are the only person who can take the enrollee to radiation therapy appointments. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this provider is out-of-network with the Plan and the enrollee can be treated at an in-network facility.  Medicare rules say that plans must make care accessible to enrollees. According to Medicare rules, care is considered accessible to an enrollee if contract providers are available within reasonable distance and travel time from the enrollee's home. The plan contract says that enrollees must use contract providers.   The provider is a non-contract provider. We were able to confirm that the Plan has contract providers located within reasonable distance and travel time from the enrollee's home who can provide consultation visit. Under Medicare rules, this means that contract providers are accessible to the enrollee. Therefore, we decided that the Plan does not have to pre-approve a radiation oncology consultation visit to be provided by an out-of-network (OON) provider.
Appeal type: Step-Therapy
Decision: Favorable

 We decided that the Plan has to pre-approve use of Euflexxa.  You asked the Plan to pre-approve Euflexxa. You say that this is a continuation of treatment. The Plan denied your request. The Plan says that the denial of authorization for this drug is correct, because the records do not show that the enrollee has tried and failed a preferred drug or has a reason they cannot use a preferred drug.  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. 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.  The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. This Plan has implemented step therapy criteria for some Medicare Part B medications. However, the Plan has not specified which preferred drugs the Plan is recommending as an alternative to Euflexxa. Without specification of the Plan's preferred drugs, we cannot determine whether the enrollee has previously tried and failed the Plan's preferred drugs or that a preferred drug would likely be less effective or have adverse effects for the enrollee. Therefore, the Plan has not shown that its decision to deny authorization for Euflexxa due to step therapy rules is correct or medically justified. Therefore, we decided that the Plan has to pre-approve use of Euflexxa.   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: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Aduhelm  You asked the Plan to pre-approve Aduhelm. You say that this drug is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage have not been met for this drug.  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 Aduhelm. Our reviewer says that the requested drug is not medically reasonable and necessary. Our physician reviewer found Aduhelm is indicated for the treatment of Alzheimer's disease, and should be initiated in patients with mild cognitive impairment or mild dementia stage of the disease, the population in which treatment was initiated in clinical trials. In this case, the documentation is inconsistent regarding the severity of the enrollee's dementia. The enrollee is on Namenda, which is indicated for the treatment of moderate to severe disease. The magnetic resonance imaging (MRI) suggests evidence of a mixed etiology for the enrollee's symptoms.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Aduhelm have not been met. Therefore, we decided that the Plan does not have to pre-approve Aduhelm
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 admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.  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 the enrollee does not need intensive therapies, consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach to daily therapy. While the enrollee may benefit from continued physical therapy, and occupational therapy, her rehab needs can be safely met in an alternate and low intensity setting such as in a skilled nursing facility.  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 skilled nursing facility (SNF) services.  You asked the Plan to pre-approve SNF services. You say that the enrollee requires around the clock care. The Plan denied your request. The Plan says the enrollee does not require skilled nursing or therapy on a daily basis as an inpatient.  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 services. Our physician reviewer found that from a nursing perspective, the enrollee received oral medications, continued dialysis, and was treated for pain. There are no identifiable skilled nursing service needs. Regarding rehabilitation services, she was at a moderate to maximal assist with bed mobility and transfers. She required varying assist with activities of daily living. There are no identifiable skilled therapy service needs. She does not require skilled nursing or therapy services on a daily basis. She 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for a short-latency somatosensory evoked potential study (procedure code 95938) provided to the enrollee on July 30, 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 the denied code remains not supported.  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 95938 is "Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in upper and lower limbs."  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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer found the documentation states "upper SSEP 95938- Upper Extremities SSEP Stimulation sites: Median Nerve. Results: Baseline upper extremity somatosensory evoked potentials were interpreted to be reproducible and reliable for neuromonitoring.  The surgeon was informed and acknowledged." There is a more appropriate code to report for this service - CPT 95925 or CPT 95938, depending on the limbs.  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 services have not been met. Therefore, we decided that the Plan does not have to pay for a short-latency somatosensory evoked potential study (procedure code 95938) provided to the enrollee on July 30, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.  You asked the Plan to pre-approve SNF services. You say that you need to go to a SNF for rehabilitation. The Plan denied your request. The Plan says you have not completed your full course of care in the hospital.  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 services. Our physician reviewer found that you are unable to sit up without maximum assistance and she is dependent for mobility and activities of daily living. She is reported to be having on-going issues with hypotension. Based on the records provided, your medical conditions appear to be too unstable for care at the nursing facility level.  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-approve skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for pain management services (procedure code 30903) provided to the enrollee on March 30, 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 Current Procedural Terminology (CPT) code 30903-RT remains not supported.  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 30903 is "Control nasal hemorrhage, anterior, complex (extensive cautery and/or packing) any method."  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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer found the procedure report documents "A trial of Afrin and nasal clamping was attempted but the patient still had nasal bleeding.   nasal balloon was placed and it did stop. Patient will be started on Augmentin and will need to follow-up with the ear nose and throat doctor. Return precautions are given. Site of bleeding was not found for cauterization." The documentation does not support extensive cautery and/or packing to support this level of service. The procedure performed describes a nasal balloon was placed, and the enrollee was referred to a specialist.  Therefore, this code would not be covered.  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 services have not been met. Therefore, we decided that the Plan does not have to pay for pain management services (procedure code 30903) provided to the enrollee on March 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the facet joint injections.  You asked the Plan to pre-approve the facet joint injections. You say that the service is medically necessary. The Plan denied your request. The Plan says there is not enough information to determine medical necessity.  The Plan follows Medicare rules. Medicare rules say that Facet Joint Interventions are considered medically reasonable and necessary for the diagnosis and treatment of chronic pain in patients who meet ALL of the following criteria:          Moderate to severe chronic neck or low back pain, predominantly axial, that causes functional deficit measured on pain or disability scale11; AND*         Pain that has been present for a minimum of 3 months with documented failure to respond to noninvasive conservative care management (as tolerated)4,12; AND         Absence of untreated radiculopathy or neurogenic claudication (except for radiculopathy caused by facet joint synovial cyst)4,7; AND         There is no non-facet pathology per clinical assessment or radiology studies that could explain the source of the patient's pain, including but not limited to fracture, tumor, infection, or significant deformity.  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 facet joint injections. Our reviewer says that the service is not medically necessary. Our physician reviewer found there is a significant lack of documentation and therefore, the request at this point, is deemed not medically reasonable or necessary.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the facet joint injections have not been met. Therefore, we decided that the Plan does not have to pre-approve the facet joint injections.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care after December 17, 2021.  You asked the Plan to pre-approve SNF care. You say that you have an unsteady gait and would have difficulty managing at home. The Plan denied your request. The Plan says the denial of authorization for continued SNF care after December 17, 2021.  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 December 17, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the implantation of carotid sinus baroreflex activation device for the enrollee.  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 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 these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. 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, analagous to a cardiac pacemaker, to the baroreceptors of one of the carotid arteries. In August 2019 the FDA approved the system for use in patients with refractory heart failure who remain symptomatic despite treatment with guideline-directed medical therapy, are 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. Our physician reviewer found that the enrollee's 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 the implantation of carotid sinus baroreflex activation device for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the transcutaneous electrical modulation pain reprocessing (TEMPR) rendered on July 16, 2021.  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 the services were 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 pay for these services. Our reviewer says that the services were not medically necessary. Our physician reviewer found the records show that you had a stroke with resulting left-sided nerve pain. The TEMPR procedure is considered experimental/investigational in nature and was therefore 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 these services have not been met. Therefore, we decided that the Plan does not have to pay for the transcutaneous electrical modulation pain reprocessing (TEMPR) rendered on July 16, 2021.