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

 We decided that the Plan does not have to pre-approve all lower extremity prostheses, flex-walk system or equal (CPT code L5981) and all lower extremity prostheses, multi-axial rotation unit (L5986).  You asked the Plan to pre-approve the items. You say that the items are necessary. The Plan denied your request. The Plan says the request for K3 foot does not meet Medicare criteria as reasonable and necessary.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the items. Our physician reviewer found the medical record does not demonstrate that you are K3 ambulator: Notes from your physician do not show that you are a K3 ambulator. Notes from physician do not show why needs cannot be met with K2 prosthesis, especially given your co-morbidities of Charcot- Marie-Tooth disease and chronic lumbar spine pain. If this part is needed, this need must be corroborated by provider without financial interest in the claim outcome, as noted above. There must be clear documentation why this part is needed, which has not been provided. The review indicates that the medical records provided do not meet the requirements listed in the LCD for Medicare coverage.  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 items have not been met. Therefore, we decided that the Plan does not have to pre-approve all lower extremity prostheses, flex-walk system or equal (CPT code L5981) and all lower extremity prostheses, multi-axial rotation unit (L5986).
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 enrollee's needs could be provided in another setting, such as an acute rehabilitation facility, skilled nursing facility, nursing facility, outpatient setting or home care.  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 power seat elevation system (CPT code E2300) and a self-leveling cup holder (K0108).  You asked the Plan to pre-approve the items. You say that the items are necessary. The Plan denied your request. The Plan says the items are 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 item at issue in this appeal does not serve a purpose that is primarily medical in nature. The items are available to the general 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 power seat elevation system (CPT code E2300) and a self-leveling cup holder (K0108).
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.  You asked the Plan to pre-approve SNF 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 Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the beneficiary does not require skilled nursing or therapy services on a daily basis. This beneficiary does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
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 this is medically necessary. The Plan denied your request. The Plan says the records do not show complex wound care or infection.  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 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing (Next Generation Sequencing) for the
enrollee.
You asked the Plan to pay for the services. You say that this is medically necessary. The Plan denied your
request. The Plan says when a panel is ordered, a panel code should be used.
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 find that the various denied CPT codes are not supported in the medical record. Specifically, the testing at
issue in this case should be reported with CPT 81479. 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 genetic testing (Next Generation Sequencing) for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an additional eight (8) routine transportation trips.  You asked the Plan to pre-approve additional routine transportation trips. You say that you are requesting an additional eight (8) trips in order to meet your provider visits. The Plan denied your request. The Plan says the requested amount exceeds the limit listed by the plan.  Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.   We looked at your request, the records in the case file, and the rules. Based on this information, the 13th trip and beyond is not a covered benefit. Your 2021 EOC says up to 12 one-way trips are covered per calendar year (limited to ground transportation only). Therefore, we decided that the Plan does not have to pre-approve an additional eight (8) routine transportation trips.
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: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).  You asked the Plan to pre-approve SNF care. You say that SNF care is medically reasonable and necessary for the enrollee's condition. The Plan denied your request. The Plan says rules for SNF care have not been met.  The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the beneficiary is a 77-year-old female with cerebrovascular accident, dysphagia, intraparenchymal hemorrhage and depression. In this case, there are no identifiable skilled nursing service needs and no identifiable skilled therapy service needs. Furthermore, the beneficiary does not require skilled nursing or therapy services on a daily basis. In conclusion, this beneficiary does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
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: Step-Therapy
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Euflexxa injections (CPT code J7323), for the enrollee.  You asked the Plan to pre-approve the injections. You say that the injections are necessary. The Plan denied your request. The Plan says there is no documentation that the enrollee has tried/failed or been intolerant of the formulary alternatives which are: Durolane, Gelsyn-3, Synvisc, Synvisc-One. The Plan states nor has the provider stated that these alternatives would be less effective and/or cause adverse side 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 injections. Our physician reviewer found the Plan requires a trial of drug formulary alternatives which are: Durolane, Gelsyn-3, Synvisc, Synvisc-One before they will approve the requested drug. In this case, the enrollee has not tried and failed the required drug(s). There is no documentation provided indicating that the plan's required drug(s) 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 injections have not been met. Therefore, we decided that the Plan does not have to pre-approve Euflexxa injections (CPT code J7323), for the enrollee.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve additional thirty-six (36) sessions of repetitive transcranial magnetic stimulation (rTMS).  You asked the Plan to pre-approve the services. You say that you are requesting completion of the enrollee's 36 session TMS therapy course in order to prevent relapse and maintain the gains the enrollee has made thus far. The Plan denied your request. The Plan says the Medicare rules have not been 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 the services.  Our physician reviewer found based on review the records provided and utilizing the Medicare LCD specifically for repetitive transcranial magnetic stimulation (L37088) specifically requires the confirmed diagnosis to be Severe Major Depressive Disorder Single or Recurrent as well as resistance the treatment with pharmacologic agents as evidenced by lack of clinical significant response to for trials of pharmacologic agents in the current depressive episode from at least two different agent classes along with concurrent documented psychotherapy. The enrollee must show a 50 percent increase in PHQ 9 during the course of treatment. Utilizing the information from this enrollee that indicates this enrollee does not have an indication for the requested Repetitive Transcranial Magnetic Stimulation (rTMS). Based on the records provided. This enrollee does not meet the criteria or treatment with Repetitive Transcranial Magnetic (rTMS) as there is no documentation of the enrollee being diagnosed with Major Depressive Disorder, Severe, taking medication in the current depressive episode, no history of psychotherapy and no documentation of improvement in the PHQ 9.  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 additional thirty-six (36) sessions of repetitive transcranial magnetic stimulation (rTMS).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a pneumatic compression device with associated arm sleeves (E0651, E0668) to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve a pneumatic compression device with associated arm sleeves to be provided by an OON provider. You say that the services are necessary. The Plan denied your request. The Plan says there are in-network providers that are able to provide these services. Therefore, coverage criteria have not been met.  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 a pneumatic compression device with associated arm sleeves (E0651, E0668) to be provided by an out-of-network (OON) provider.
Appeal type: Other
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve railings for outside and inside garage stairs.  You asked the Plan to pre-approve the items. You say that this would help with your stability, would be used to leave and enter the house. You state you need at least two (2) people to get anywhere, without this added stability. The Plan denied your request. The Plan says railings are not reasonable and necessary as they are considered a convenience item; not primarily medical in nature.  The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general 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 railings for outside and inside garage stairs.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve endoskeletal knee-shin system, single axis, fluid swing and stance phase control (CPT code L5828), endoskeletal, knee-shin system, stance flexion feature, adjustable (L5845), endoskeletal system, above knee or hip disarticulation, knee extension assist (L5850), and endoskeletal system, above knee, knee disarticulation or hip disarticulation, manual lock (L5925), for the enrollee.  You asked the Plan to pre-approve the services. You say that the computerized knee is needed because the enrollee changes speeds fast, and they climb ladders and stairs. You state this also justifies that the enrollee would use the computerized knee for more than simple walking. The Plan denied your request. The Plan says the request for prosthesis with microprocessor knee does not meet Medicare criteria as reasonable and necessary.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our physician reviewer found the provided notes do not show why a heavier microprocessor knee would be indicated for this enrollee, given the enrollee's multiple comorbidities, especially for an initial knee. Further, the enrollee is alleged to enjoy "football, hunting and fishing, bicycling." A microprocessor is more prone to damage and corrosion, especially when exposed to water. Notes do not show why this would be reasonable and necessary for this enrollee's initial knee. The review indicates that the medical records provided do not meet the requirements listed in the LCD for Medicare coverage.      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 endoskeletal knee-shin system, single axis, fluid swing and stance phase control (CPT code L5828), endoskeletal, knee-shin system, stance flexion feature, adjustable (L5845), endoskeletal system, above knee or hip disarticulation, knee extension assist (L5850), and endoskeletal system, above knee, knee disarticulation or hip disarticulation, manual lock (L5925), for the enrollee.