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 you disagree with the denial. The Plan
denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. 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 medically necessary. Our physician reviewer found the enrollee was
admitted on December 9, 2021 for a higher level of care after being admitted to another acute care facility on
December 4, 2021 for sepsis due to pneumonia, cardiac arrest with intubation and vasopressor support on
December 8, 2021. The enrollee does not require services at the LTACH that are not available at the acute care
hospital where he 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 pay for the supplies rendered on June 15, 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 procedure codes S1015 and S8301 are not covered.
The Plan must follow Medicare rules. The rules say that a status indicator of I represents a code that is not valid
for Medicare purposes.
We looked at the file and Medicare rules. Billed procedure codes S1015 (intravenous tubing extension set) and
S8301 (infection control supplies) have a status indicator of I and are not valid for Medicare purposes.
Therefore, we decided that the Plan does not have to pay for the supplies rendered on June 15, 2021
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve drug testing (G0482, G0480, G0481, G0483).
You asked the Plan to pre-approve the drug testing. You say that the services are medically necessary. The Plan
denied your request. The Plan says that coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that Controlled Substance Monitoring and Drugs of
Abuse Testing is covered when 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 drug testing. Our reviewer says that
the requested drug testing is medically necessary. Our physician reviewer found the enrollee has tested positive
for Alcohol, THC and an abnormal creatinine in the past. While the patient denies substance abuse, these
abnormal results warrant further testing.
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 drug testing have been met. Therefore, we decided that the Plan has to pre-
approve drug testing (G0482, G0480, G0481, G0483).
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: Favorable

We decided that the Plan has to pre-approve Evenity.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied
your request. The Plan says that the services are not medically necessary.
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.
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. The Plan states that the Evenity is not medically necessary; however, no medical
records have been provided for review. Without medical records, a determination based on medical necessity
cannot be supported. Therefore, we decided that the Plan has to pre-approve Evenity.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve repeat radiofrequency ablation (RFA).
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied
your request. The Plan says a third series not covered.
The Plan must follow Medicare rules. The rules say that for each covered spinal region no more than two (2)
radiofrequency sessions will be reimbursed per rolling 12 months.
We looked at the file and Medicare rules. The file shows that the enrollee has received RFA to the requested
level two times in the past 12 months. 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 repeat
radiofrequency ablation (RFA).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Tadalafil.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied
your request. The Plan says self-administered drugs are not covered.
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 Tadalafil.
Benefits for these services 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care services rendered on April 24, 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 procedure code 99291 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.
In this case, the CPT Code Manual definition of code 99291 is critical care, evaluation and management of the
critically ill or critically injured patient; first 30-74 minutes.
We find that CPT code 99291 is not supported in the medical record. Specifically, there is no documentation of
the time spent providing critical care services. 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
critical care services rendered on April 24, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gammagard liquid 10% vial for the enrollee.
You asked the Plan to pre-approve the vial. You say that this is medically necessary. The Plan denied your
request. The Plan says the enrollee's plan has Part A and B coverage, with no Part D drug coverage.
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B,
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill.
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be
brought to the office for administration. Since the medication does not represent an expense to the physician
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that
the Plan does not have to pre-approve Gammagard liquid 10% vial for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Brovana for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is needed to treat chronic obstructive pulmonary
disease and asthma. The Plan denied your request. The Plan says there is no indication that Perforomist would
likely be less effective and/or cause adverse effects.
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 drug. Our reviewer says that the
requested drug is not medically reasonable or necessary. Our physician reviewer found based on the medical
records provided, the enrollee has not tried and failed Perforomist. There is no indication that this drug would
likely be less effective and/or likely have adverse effects for the enrollee.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the drug have not been met. Therefore, we decided that the Plan does not have
to pre-approve Brovana for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Gel-One injection for the enrollee.
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your
request. The Plan says there are preferred alternatives available.
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. Our reviewer says that the
requested services are not medically reasonable or necessary. Our physician reviewer found the enrollee has
not trialed viscosupplemental treatments such as Euflexxa, Durolane, Supartz-FX, and Gelysn-3. Step therapy,
as outlined by the plan, requires that these be trialed first. The documentation does not outline contraindications
or reasons these medications were not considered or that the plan's required drugs would likely be less
effective and/or likely have adverse effects for the enrollee. Without the support of the documentation, Gel-One
is not approved as step criteria have not been met.
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 a Gel-One injection for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a commercial recliner with elevated leg rests.
You asked the Plan to pre-approve a commercial recliner with elevated leg rests. You say that a commercial
recliner with elevated leg rests is medically necessary. The Plan denied your request. The Plan says a
commercial recliner with elevated leg rests is not covered by Medicare.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose. A commercial recliner with elevated leg rests does not serve a purpose that is primarily
medical in nature. This item is available to the public and would be helpful even to those who are not sick or
injured. Therefore, we decided that the Plan does not have to pre-approve a commercial recliner with elevated
leg rests.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided on April 9, 2021,
through April 12, 2021.
You asked the Plan to pay for acute inpatient hospital care. You say that you would like reconsideration
because the inpatient hospital services were medically necessary. The Plan denied your request. The Plan says
the member did not meet Medicare criteria for coverage of the inpatient hospital services.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases,
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or
more.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our
physician reviewer found based on the provided notes, the member did not present with a complex clinical
scenario and he tolerated debridement without issue. It was not expected that the member would require
hospital services that would cross 2 midnights.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the
Plan does not have to pay for the acute inpatient hospital care provided on April 9, 2021, through April 12,
2021
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve LTACH services.  You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary based on the LTACH criteria. The Plan states the current acute care hospital can provide acute care services until the enrollee's condition allows transfer to an alternate level of care, such as skilled nursing facility, acute inpatient rehabilitation, home health care, nursing home, or home.  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 there is no documentation provided indicating medical necessity for admission to a LTACH. The enrollee is receiving appropriate care at the present acute care facility. The enrollee does not require services at the LTACH that are not available at the acute care hospital where they are 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 LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve LTACH services.  You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.  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 there is no documentation provided indicating medical necessity for admission to a LTACH. The enrollee is receiving appropriate care at the present acute care facility. The enrollee does not require services at the LTACH that are not available at the acute care hospital where they are 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 LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve FreeStyle Libre 14 Day Reader Device (CPT code K0554), for the enrollee.  You asked the Plan to pre-approve the device. You say that the device is necessary. The Plan denied your request. The Plan says the Medicare rules have not been met.  The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan.     We looked at the file and Medicare rules. The documentation does not show that the enrollee is injecting insulin three (3) or more times per day or is using a Medicare-covered continuous subcutaneous insulin infusion (CSII) pump. The documentation shows that the enrollee is treated with two (2) insulin injections daily. Based on this information, we decided that Medicare rules for coverage of the device have not been met. Therefore, we decided that the Plan does not have to pre-approve FreeStyle Libre 14 Day Reader Device (CPT code K0554), for the enrollee.
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 services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has 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 the review has determined 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. 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the CGM system receiver and sensors (CPT code(s): K0554 and K0553).  You asked the Plan to pre-approve the items. You say that you are upset you cannot get a refill of you Freestyle Libre sensor covered. The Plan denied your request. The Plan says the Medicare rules have not been met.  The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan.    We looked at the file and Medicare rules. The documentation does not show that you are on multiple daily doses of insulin, and your current treatment regimen does not involve frequent blood sugar adjustments. Based on this information, we decided that Medicare rules for coverage of the items have not been met. Therefore, we decided that the Plan does not have to pre-approve the CGM system receiver and sensors (CPT code(s): K0554 and K0553).