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

 We decided that the Plan does not have to pre-approve acute IRF admission and services.  You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary based on IRF criteria. The Plan states your records received do not indicate you need an intensive therapy program with multiple visits from a rehabilitation doctor per week. The Plan states you can safely receive the services you need in other settings, for example: a skilled nursing facility, home with home health and home physical therapy.  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 complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for weakness, falls, and right radial fracture. Medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While you have 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 you 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 IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve surgical placements of implant bodies: endosteal implants (D6010).  You asked the Plan to pre-approve the endosteal implants. The Plan denied your request. The Plan says this service is not covered under your benefit plan.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve surgical placements of implant bodies: endosteal implants (D6010).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve manual lymphatic drainage massage therapy and hydrotherapy to be provided by an out-of-network (OON) provider.  

You asked the Plan to pre-approve the outpatient services. You say that all you are asking for is to be seen by a knowledgeable provider. If the Plan continues to refuse to provide the proper treatment plan, the surgeries being performed will be of no use and the lipedema will continue to progress. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services.  

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.  

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve manual lymphatic drainage massage therapy and hydrotherapy to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve lithotripsy procedure to be provided by an out-of-network provider.  You asked the Plan to pre-approve the out-of-network services. You say that the service is necessary. The Plan denied your request. The Plan says researched and confirmed with an in-network providers office that the in-network doctor can provide the service, is accepting new patients and has appointments available within three (3) weeks to one (1) month and is within the Medicare allowable distance and time.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.  The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve lithotripsy procedure to be provided by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a Trilogy Noninvasive Ventilator for the enrollee.  You asked the Plan to pre-approve a Trilogy Noninvasive Ventilator. You say that this is medically necessary. The Plan denied your request. The Plan says that there is not sufficient detailed information in the medical records from the doctor or from the hospital records to justify the medical necessity of Trilogy noninvasive ventilator rather than BiPAP.  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 a Trilogy Noninvasive Ventilator. Our reviewer says that a Trilogy Noninvasive Ventilator is not medically reasonable and necessary. There is not sufficient detailed information in the medical records to justify the medical necessity of Trilogy noninvasive ventilator rather than BiPAP. The patient does not have neuromuscular disease, thoracic restrictive disease, or chronic respiratory failure consequent to chronic obstructive pulmonary disease. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for a Trilogy Noninvasive Ventilator.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a Trilogy Noninvasive Ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a Trilogy Noninvasive Ventilator for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a Humalog KwikPen.  You asked the Plan to pre-approve Humalog KwikPen. You say that the enrollee has a difficult time drawing insulin due to eyesight impairment. You also say that pre-loaded injector pens have been helpful for the enrollee. The Plan denied your request. The Plan says the requested drug is considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the requested drug is not covered under Medicare Part B.  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 a Humalog KwikPen.   Benefits for Humalog KwikPen 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: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an epidural steroid injection (ESI).  You asked the Plan to pre-approve the ESI. The Plan denied your request. The Plan says the coverage criteria are not met.  The Plan follows Medicare rules. Medicare rules say that ESIs are limited to a maximum of four (4) sessions per spinal region in a rolling twelve (12) month period.  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 ESI. Our reviewer says that the requested ESI is not medically reasonable and necessary. Our physician reviewer found that the enrollee has already had 4 ESIs since March 3, 2021. The requested ESI is not medically reasonable or necessary according to the coverage criteria established in the above LCD.  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 ESI have not been met. Therefore, we decided that the Plan does not have to pre-approve an epidural steroid injection (ESI).
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a laparoscopic sleeve gastrectomy procedure.  You asked the Plan to pre-approve the requested services. You say that your legs hurt a lot. The Plan denied your request. The Plan says you do not have the required conditions for coverage.  The Plan must follow Medicare rules. Medicare rules say that surgical management of morbid obesity are only covered under certain medical indications.   We looked at the file and Medicare rules. In this case, the medical records do not document that the enrollee has tried and failed to achieve a health body weight with adequate participation in healthy eating and physical exercise. Based on this information, we decided that Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve a laparoscopic sleeve gastrectomy procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an office visit to be provided by the requested out-of-network provider.

  You asked the Plan to pre-approve an office visit to be provided by the requested out-of-network provider. You say that you were recently diagnosed with a cataract in your left eye, and you are unhappy with your current ophthalmologist. The Plan denied your request. The Plan says out-of-network services are not approved unless they are not available in the network or are emergent. The medical records did not show an acute medical emergency and the member appears medically stable and this service can be provided by a contracted ophthalmologist.  

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.  

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve an office visit to be provided by the requested out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Freestyle Libre continuous glucose monitoring supplies.  You asked the Plan to pre-approve Freestyle Libre continuous glucose monitoring supplies. You say that this is medically necessary. The Plan denied your request. The Plan says the requirements for coverage 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 you do not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of Freestyle Libre continuous glucose monitoring supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve Freestyle Libre continuous glucose monitoring supplies.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the inpatient hospital care provided from May 26, 2021, through May 29, 2021, as billed with principal diagnosis code R78.81 and secondary diagnosis code G93.41.  You asked the Plan to pay for the inpatient hospital care as billed. You say that this claim has been billed appropriately. The Plan denied your request. The Plan says the documentation does not support the billed diagnosis codes.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes.    In this case, you billed the inpatient services provided with the principal diagnosis code, R78.81, defined as bacteremia and secondary diagnosis code, G93.41, defined as metabolic encephalopathy. 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 inpatient hospital care as billed. Our reviewer says that the documentation does not support the inpatient hospital care as originally billed. Our physician reviewer found the review indicates that the enrollee was a then 92-year-old female with a history of senile dementia of Alzheimer's type, coronary artery disease, and atrial fibrillation who presented to the emergency department on May 26, 2021, with mental status changes. Evaluation revealed a urinary tract infection, and she was treated with IV antibiotics. Cultures revealed E coli bacteremia. Her condition stabilized and improved, and she was discharged on May 29, 2021, on oral antibiotic therapy. There was no documentation of metabolic encephalopathy during the evaluation/hospitalization. The review has determined that the documentation supports that the Plan was correct in changing the principal diagnosis code to N30.01, acute cystitis with hematuria and the secondary diagnosis code to R78.81, bacteremia. There is no support for a diagnosis code of G94.31, metabolic encephalopathy.   We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for the inpatient hospital care provided from May 26, 2021, through May 29, 2021, as billed with principal diagnosis code R78.81 and secondary diagnosis code G93.41.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for the services (29828) provided on March 15, 2021.  You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is 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.  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 use of code 29828 is not supported by the records provided. Our reviewer found that the operative report describes a bicep tenodesis performed by arthroscopic and mini open. As these two procedures cannot both be reported, the mini open procedure should be reported with the appropriate modifier.  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 the services (29828) provided on March 15, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Granix.  You asked the Plan to pre-approve Granix. You say that this is medically necessary. The Plan denied your request. The Plan says that the member has not tried and failed their preferred step therapy drugs.  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 Granix. Our reviewer says that Granix is not medically reasonable and necessary. The Plan requires a trial of Nivestym and Zarxio before they will approve the requested drug. In this case, you have not tried and failed the required drugs. There is no documentation provided indicating that the Plan's required drugs would likely be less effective and/or likely have adverse effects for you. Our physician reviewer found that your condition does not meet step therapy criteria for Granix.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Granix have not been met. Therefore, we decided that the Plan does not have to pre-approve Granix.
Appeal type: Imaging
Decision: Favorable

 We decided that the Plan has to pre-approve magnetic resonance imaging (MRI) services.  You asked the Plan to pre-approve the MRI. You say that a screw and plate was inserted into her neck. You say that the screw is loose, and the plate is off. You say that this has caused severe pain. You say that the MRI is needed so that the surgeon can tighten the screw and adjust the plate. The Plan denied your request. The Plan says that an MRI is not recommended for the enrollee's medical issue.  The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically necessary.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the MRI. Our reviewer says that the criteria for coverage have been met. Our physician reviewer found the enrollee has a complication from previous neck surgery with a loose plate. The MRI is needed to see if any additional work needs to be done in the surgery for plate removal. The MRI will show if there is any residual canal stenosis. It is medically needed.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the MRI have been met. Therefore, we decided that the Plan has to pre-approve magnetic resonance imaging (MRI) services.   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: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve acute IRF admission and services.  You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary based on IRF criteria. The Plan states there is nothing to show the enrollee needs physician supervision at least three (3) times per week, so care can be provided at a lower level. The Plan states they can approve a skilled nursing facility admission for the enrollee to get therapy.  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 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 was admitted for total knee replacement. Medical problems are stable. There are no complex nursing or rehabilitation needs. 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 this 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 IRF admission and services.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Metformin for the enrollee.  You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your request. The Plan says that this is not covered under Part B.  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 Metformin for the enrollee.      Benefits for this drug may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.