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

 We decided that the Plan does not have to pre-approve a home sleep study.  You asked the Plan to pre-approve a home sleep study. The Plan denied your request. The Plan says a home sleep study is not needed since your obstructive sleep apnea was confirmed in the past earlier this year with AHI 69.  The Plan follows Medicare rules. Medicare rules say that effective for claims with dates of service on and after March 3, 2009, the Centers for Medicare & Medicaid Services finds that the evidence is sufficient to determine that the results of the sleep tests identified below can be used by a beneficiary's treating physician to diagnose OSA, that the use of such sleep testing technologies demonstrates improved health outcomes in Medicare beneficiaries who have OSA and receive the appropriate treatment, and that these tests are thus reasonable and necessary under section 1862(a)(1)(A) of the Social Security Act.  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 home sleep study. Our reviewer says that a home sleep study is not medically necessary. Our physician reviewer found the enrollee is a 64-year-old female with reported snoring, daytime sleepiness, Epworth sleepiness scale of 10, and prior history of obstructive sleep apnea (OSA) using continuous positive airway pressure (CPAP) at night. The enrollee wanted to discuss the Inspire procedure. A home sleep study was requested. The provided documentation did not clearly explain why repeat sleep study was needed to continue care with the CPAP. Based on the provided documentation, the Medicare criteria is not met as continued use of CPAP was recommended to this enrollee without a major change in treatment or adjustment 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 a home sleep study have not been met. Therefore, we decided that the Plan does not have to pre-approve a home sleep study.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the group two power wheelchair replacement (K0823).  You asked the Plan to pre-approve the group two power wheelchair replacement. You say that the item is medically necessary. The Plan denied your request. The Plan says the item is not medically necessary.  The Plan follows Medicare rules. The rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment.   We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Specifically, there were no medical records provided in this case. Without the medical records, we cannot review to see if the services were urgent/emergent or medically necessary.  Therefore, we decided that the Plan does not have to pre-approve the group two power wheelchair replacement (K0823).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for optometry services (92014, 92015, 92134) provided on August 17, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the optometry services. You say that the services should be covered. The Plan denied your request. The Plan says the provider is out-of-network and you do not have any out-of-network benefits.  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 pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.    The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for optometry services (92014, 92015, 92134) provided on August 17, 2021, by an out-of-network (OON) provider.
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 requires IRF care to maintain her well-being and for preventative measures. The Plan denied your request. The Plan says the criteria for admission to the IRF setting have not been met. The enrollee's ongoing skilled therapy and nursing needs can be provided at a lower level of care.  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 LTACH services.  You asked the Plan to pre-approve the LTACH services. You say that the admission is medically necessary. The Plan denied your request. The Plan says the requested admission 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 the provided documentation indicates the enrollee is receiving appropriate care at the present acute care hospital. The documentation indicates the enrollee does not require services at the long-term acute care hospital (LTACH) that are not available at the acute care hospital where they are currently receiving care. The reviewer found 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. Therefore, the reviewer found that 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. Specifically, the file shows that the enrollee is receiving appropriate care at the present acute care hospital. Therefore, we decided that the Plan does not have to pre-approve LTACH services.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a Humira Pen.  You asked the Plan to pre-approve a Humira Pen. You say that the drug is medically necessary. The Plan denied your request. The Plan says this drug is on the self-administered drug list and is excluded from coverage 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 a Humira Pen.   Benefits for a Humira Pen 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: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the power standing system (CPT code E2301), power seat elevation system (E2300), expandable controller, including all related electronics and mounting hardware, upgrade provided at initial issue (E2377), harness for upgrade to expandable controller (E2313), electronic connection between wheelchair controller and two or more power seating system motors (E2311), and custom roho cover (K0108 x2).  You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your request. The Plan says the DME is not covered.  The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.    The seat lift and standing system do not serve a medical purpose. These cannot be covered. The upgraded electronics (expandable controller, harness and electronic connector to 2 power options) are not medically necessary. They are necessary when there is a medical need to control power options though the joystick. The notes do not show a medical need to control the power options through the joystick. The power options can be controlled using their own switches. These switches can be made any size without asking for a separate request. They can be made from any material without asking for a separate request. All of this can be done without the need to use the joystick to control the power features. The cover is already included with the approved cushion. Therefore, we decided that the Plan does not have to pre-approve the power standing system (CPT code E2301), power seat elevation system (E2300), expandable controller, including all related electronics and mounting hardware, upgrade provided at initial issue (E2377), harness for upgrade to expandable controller (E2313), electronic connection between wheelchair controller and two or more power seating system motors (E2311), and custom roho cover (K0108 x2).
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 you need LTACH care in order to come off the ventilator properly and do physical therapy in order to rehabilitate enough to go home. The Plan denied your request. The Plan says the criteria for admission to the LTACH have not been met. Your medical needs are being met in the current acute setting.  The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found that you do not require services at the LTACH that are not available at the acute care hospital where you are currently receiving care.  All medically necessary care is being provided in the current acute care facility. There are no services available at the LTACH that you require that are not available at the health care setting being offered by the health plan. The health plan has approved ongoing care in the current acute care facility. The requested LTACH services are not medically necessary, reasonable, and appropriate for your diagnosis and condition 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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an epidural steroid injection, lumbar (64483).  You asked the Plan to pre-approve injection. You say that the requested service is medically necessary. The Plan denied your request. The Plan says there is insufficient documentation of the previous lumbar epidural steroid injection having provided sustained improvement for 3 months or more.  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 injection. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is insufficient documentation of the previous lumbar epidural steroid injection having provided sustained improvement for 3 months or more. Therefore, without sufficient time passing since the last injection or detail report of measurable functional benefit, this request for repeat epidural injection will be considered not medically necessary at this time.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of injection have not been met. Specifically, the file does not show that the previous lumbar epidural steroid injection having provided sustained improvement for 3 months or more. Therefore, we decided that the Plan does not have to pre-approve an epidural steroid injection, lumbar (64483).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a Group 3 power wheelchair (PWC) with tilt and recline.  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 the services are not medically necessary.  The Plan must follow Medicare rules. Medicare rules say that a Group 3 PWC is covered when specific criteria are met.  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 services are not medically necessary. Our physician reviewer found the records do not show that the enrollee has a neurologic disorder with functional deficits. She meets the criteria for coverage of a power mobility device; however, the criteria for the Group 3 PWC are not met. The services are 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 pre-approve a Group 3 power wheelchair (PWC) with tilt and recline.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Procrit (J0885).  You asked the Plan to pre-approve Procrit. You say that the requested drug is medically necessary. The Plan denied your request. The Plan says the requested drug is not medically necessary.  The Plan follows Medicare rules. Medicare rules say that Epoetin alfa-epbx (biosimilar) is covered for use in specific patients who are at high risk for perioperative blood loss prior to surgery to reduce risk of transfusion.  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 Procrit. Our reviewer says that the request for Procrit is not medically necessary. Our physician reviewer found the provided documentation indicates that the enrollee is noted to have a history of cancer, for which he is not actively on chemotherapy or hormonal therapy. The reviewer found that the enrollee has microcytic anemia and low iron levels, despite taking oral iron supplements. There is no evidence of CKD, HIV, MDS or Hepatitis C. The reviewer found that while the enrollee plans to undergo elective, non-cardiac, non-vascular surgery, his hemoglobin level is already below 10g/dL. Therefore, the reviewer found that the enrollee does not have a medically accepted indication for the use of Procrit.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Procrit have not been met. Specifically, the file does not show that you have an anemia with a hemoglobin > 10 to < 13 gm/dL. Therefore, we decided that the Plan does not have to pre-approve Procrit (J0885).
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Ozempic.  You asked the Plan to pre-approve Ozempic. You say that the enrollee needs this medication to help control type 2 diabetes. The Plan denied your request. The Plan says this drug is not covered for the enrollee's condition by their Medicare Part B plan.  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 Ozempic.        Benefits for Ozempic 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 Eliquis.  You asked the Plan to pre-approve Eliquis. You say that the enrollee is taking Eliquis for chronic atrial fibrillation, and is at high risk for stroke without it. The Plan denied your request. The Plan says Eliquis is a self-administered drug and does not fall under Part B coverage.  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 Eliquis.   Benefits for Eliquis 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: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve continued partial hospitalization services beyond January 8, 2022.  You asked the Plan to pre-approve the partial hospitalization services. The Plan denied your request. The Plan says this is 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 pre-approve the partial hospitalization services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that based upon review the records provided for the dates in question, the enrollee was not showing any dangerousness to self or others, tolerating treatment, and not showing any perceptual disturbance or psychosis. In cases such as this an evidence-based, objective instrument such as the American Association of Community Psychiatrists Level of Care Utilization System is indispensable in determining necessary level of care for adults. In terms of Risk of Harm, the records support a score of 1 due to a lack of current suicidal ideation and no self-harming behaviors. With regards to Functional Status, the records support a score of 1 due to no problems with comorbidity. In terms of Medical, Addictive and Psychiatric Comorbidity, the records support a score of 1 due to overall medical stability. In terms of level of stress of the Recovery Environment, the records support a score of 1 due to a stable living situation. With regards to Level of Support for the recovery environment, the records support a score of 1 due to availability of treatment resources. With regards to Treatment and Recovery History, the records support a score of 1 due to recent success at the partial treatment level of care. In terms of Engagement and Recovery Status, the records support a score of 1 due to cooperation in treatment and insight into his need for treatment along with insight into his treatment needs. Thus, the patient has a composite score of 7. This correlates with treatment in a community-based outpatient clinic setting. The requested partial hospitalization program services are not medically necessary for the treatment of this enrollee's condition.  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 partial hospitalization services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued partial hospitalization services beyond January 8, 2022.