Persius/hicric huggingface dataset:
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 you do 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 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from May 1, 2020, through May 10, 2020 billed with code IACD1.  You asked the Plan to pay for the SNF services as billed. You say that this was billed correctly. The Plan denied your request. The Plan says there are unsupported diagnoses reported on the MDS assessment which means that the billed HIPPS code is not supported.  The Plan follows Medicare rules. Medicare rules say that SNF services are paid based on a HIPPS code which is comprised of various components. These components are calculated based on a MDS assessment which must conform to the criteria listed in the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual.  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 SNF services as billed. Our reviewer says that the documentation does not support that the enrollee meets the criteria for reporting isolation status, nor chronic respiratory failure. Our physician reviewer found there is no documentation of an active infection to justify reporting isolation. In addition, there is no evidence showing that there was a physician documented diagnosis of chronic respiratory failure or that this had a direct relationship on the care provided during this stay.  We looked at this physician's review, the file, and Medicare rules. Because the conditions are found to be unsupported, this would affect the correct case-mix grouping for this admission. Based on this information, we decided that Medicare rules for coverage of the SNF services as billed have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from May 1, 2020, through May 10, 2020 billed with code IACD1.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the Barostim Neo system.  You asked the Plan to pre-approve the Barostim Neo system. You say that this device is medically reasonable and necessary for the enrollee's condition. The Plan denied your request. The Plan says the requested device is considered experimental/investigational at this time.  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 Barostim Neo system. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found The Barostim Neo system is an electronic pulse generator implanted underneath the clavicle with a lead tunneled under the skin to the carotid sinus in the neck. The pulse generator delivers electrical impulses, analogous to a cardiac pacemaker, to the baroreceptors of one of the carotid arteries.     In August 2019 the Food and Drug Administration (FDA) approved the system for use in patients with refractory heart failure who remain symptomatic despite treatment with guideline-directed medical therapy, are New York Heart Association (NYHA) Class III, have an ejection fraction less than 35%, and are not candidates for bi-ventricular pacing. This was based on a clinical study demonstrating improvement in normal daily activities, distance walked, quality of life, and improved cardiac levels biomarker levels. There remains an absence of randomized, blinded clinical studies examining long-term clinical outcomes establishing the value of Barostim Neo in patient management. As a result, at this time the Barostim Neo system would not be considered medically reasonable and necessary in this patient's clinical management.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Barostim Neo system have not been met. Therefore, we decided that the Plan does not have to pre-approve the Barostim Neo system.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the moderate sedation services (99153) provided on March 26, 2020.  You asked the Plan to pay for code 99153. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  We looked at the file and Medicare rules. In this case, the review shows that the medical records provided represent professional charges; however, procedure code 99153 was provided in a facility with a place of service code of 22. Procedure code 99153 has a PC/TC Modifier Status of 3, which specifies a Technical Component only code. Therefore, we decided that the Plan does not have to pay for the moderate sedation services (99153) provided on March 26, 2020.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve non-emergency ambulance transportation (A0428).  You asked the Plan to pre-approve non-emergency ambulance transportation. You say that the services are necessary. The Plan denied your request. The Plan says the services at issue are not medically necessary.  Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules.   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 non-emergency ambulance transportation. Our reviewer says that documentation does not support that the ambulance transport is medically reasonable and necessary for the enrollee. Our physician reviewer found the records indicate the enrollee is clinically stable.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of non-emergency ambulance transportation have not been met. Therefore, we decided that the Plan does not have to pre-approve non-emergency ambulance transportation (A0428).
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 the LTACH is the best option for the enrollee to meet their recovery goals. The Plan denied your request. The Plan says the criteria for admission to an LTACH are not met. The enrollee's medical needs are being met in the current acute setting. The LTACH would add no additional services. With additional time in the current setting, clinical stability can be ensured such that the appropriate level of care can be determined.  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 although the record indicates that the enrollee is improving, she continues to have ongoing acute care needs. The enrollee is currently receiving acute care services, and these have not been denied. The medical record does not indicate that the enrollee requires services that she is not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules are not satisfied; the requested service cannot be recommended. 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: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services for the enrollee.  You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that there are no noted daily skilled complex nursing or therapy needs which would meet the guidelines for continued SNF services.  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 reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for continued SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve additional power wheelchair accessories (E0978, K0108, K0108).  You asked the Plan to pre-approve the accessories. You say that this is medically necessary. The Plan denied your request. The Plan says these codes cannot be approved.  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 accessories. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the items in appeal exceed your medical need and are not medically necessary per the Social Security Act, Section 1862 (a)1(A) and the 42 CFR ?411.15(k), as Medicare does not pay for any items or services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. The K0108 unoccupied tie down kit does not serve a primary medical need within your home. The E0978 wheelchair safety belt strap and K0108 swing away leg rest x 2 exceed your medical need as they are already included in the approved K0823 wheelchair base and are therefore not 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 the accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve additional power wheelchair accessories (E0978, K0108, K0108).
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve use of Prolia.  You asked the Plan to pre-approve Prolia. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because the Plan requires a trial of oral and intravenous bisphosphonates before it will approve Prolia.  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 Prolia. Our reviewer says that the enrollee does not meet the Medicare criteria for a step therapy exception for Prolia. Our physician reviewer found the enrollee has not tried and failed the Plan's preferred drugs of oral and intravenous bisphosphonates (such as alendronate, ibandronate, risendronate, and zoledronic acid). There is no documentation indicating that these drugs would likely be less effective and/or 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 Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve use of Prolia.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an magnetic resonance imaging (MRI) brain (including brain stem) (70551).  You asked the Plan to pre-approve an MRI. You say that the enrollee has had progressive memory loss. The MRI will help with identifying other kinds of dementia. The Plan denied your request. The Plan says thorough cognitive testing was not done therefore, the medical necessity criteria has not been met.  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 an MRI. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the record indicates that the enrollee has gradual memory loss of unknown etiology.  The record indicates that a work-up is being performed and then a referral to neurology will be requested. The record does not indicate the occurrence of acute injury. The record indicates a normal neurologic examination and psychiatric examination but does not include a cognitive function examination. The requested service is not medically necessary and reasonable for the diagnosis and treatment for the enrollee's clinical condition 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 an MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve an magnetic resonance imaging (MRI) brain (including brain stem) (70551).
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the insertion of a Vertiflex device (22869, 22870).  You asked the Plan to pre-approve the insertion of a Vertiflex device. You say that this is medically necessary. The Plan denied your request. The Plan says this is experimental.  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 insertion of a Vertiflex device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental. More research is needed to show it is safe and effective.  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 insertion of a Vertiflex device have not been met. Therefore, we decided that the Plan does not have to pre-approve the insertion of a Vertiflex device (22869, 22870).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the IV tubing extension set (S1015) and the infection control supplies (S8301) provided on May 6, 2021.  You asked the Plan to pay for codes S1015 and S8301. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.  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 looked at the file and Medicare rules. In this case, CPT codes S1015 and S8301 have a status code of "I" under the Medicare Physicians Fee Schedule Database (MPFSDB) and are not valid for Medicare purposes. Medicare uses other codes for reporting of, and payment for, these services. Therefore, we decided that the Plan does not have to pay for the IV tubing extension set (S1015) and the infection control supplies (S8301) provided on May 6, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve endoskeletal knee-shin system, fluid stance extension, dampening feature (L5848) addition, endoskeletal, knee-shin system, stance flexion feature, adjustable (L5845) endoskeletal knee-shin system, single axis, fluid swing and stance phase control (L5828) addition to lower extremity prosthesis, endoskeletal knee-shin system, microprocessor control feature, swing and stance phase, includes electronic sensor(s), any type (L5856).  You asked the Plan to pre-approve computerized knee and advanced foot. You say that the enrollee is an active pastor in the area. He travels a great deal to other churches. At this time the enrollee is forced to depend on crutches for transfer. The Plan denied your request. The Plan says the request for the computerized knee and advanced foot does not meet the Medicare criteria.  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 computerized knee and advanced foot. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the medical records do not show why a mechanical k3 knee cannot be used for the enrollee's initial prosthesis especially given the weight of a microprocessor knee and the enrollee's co-morbidities. Furthermore, records from suppliers or healthcare providers with financial interest in the claim outcome are not considered sufficient by themselves for determining that an item is reasonable and necessary. The prosthetist is the vendor and therefore has financial interest in the claim. The signed physician order is for a microprocessor knee (L5848, L5845, L5828, L5856), but the office visit note makes no mention of member requiring features that are not available with a mechanical knee. The computerized knee exceeds the enrollee's medical needs. The mechanical knee will fulfill his needs as a community ambulator, and the enrollee plans to continue with physical therapy as per the records. A mechanical knee can safely fulfill all of patient's ADL needs.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of computerized knee and advanced foot have not been met. Therefore, we decided that the Plan does not have to pre-approve endoskeletal knee-shin system, fluid stance extension, dampening feature (L5848) addition, endoskeletal, knee-shin system, stance flexion feature, adjustable (L5845) endoskeletal knee-shin system, single axis, fluid swing and stance phase control (L5828) addition to lower extremity prosthesis, endoskeletal knee-shin system, microprocessor control feature, swing and stance phase, includes electronic sensor(s), any type (L5856).
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a home health aide and skilled nursing services.  You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the information does not support the need for a home health aide to make visits.  The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found based on the medical records provided, there is no documentation that skilled nursing services are required to effectively provide treatment, care, and/or services in order to improve the enrollee's condition, or to establish/perform a maintenance program to maintain the enrollee's condition and/or prevent deterioration. The records do not document any acute or unstable medical conditions or changes in medication or treatment which would necessitate any further skilled nursing visits beyond what have already been approved.   We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pre-approve a home health aide and skilled nursing services.