Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health skilled nursing services.
You asked the Plan to pre-approve home health skilled nursing services. You say that the requested home
health skilled nursing services are medically necessary. The Plan denied your request. The Plan says the
requested home health skilled nursing services are not medically necessary.
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically
necessary for the enrollee to receive skilled nursing or therapy.
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 home health skilled nursing services.
Our reviewer says that the requested home health skilled nursing services are not medically necessary. Our
physician reviewer found in this case, the documentation doesn't support that the member requires skilled
nursing services or skilled rehab services to provide treatment that is medically necessary. The member does
not require skilled nursing or rehab services to effectively provide treatment, care, and/or services in order to
improve the member's condition, perform a maintenance program to maintain the member's condition and/or
prevent deterioration. The member has been medically stable without any recent exacerbations of chronic
medical problems or hospitalizations. There are no physician orders to state what the skilled nursing needs are
for or how many visits the member will need. Furthermore, it is not clear that he is homebound. The requested
home health services are 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 home health skilled nursing services have not been met. Therefore, we decided
that the Plan does not have to pre-approve home health skilled nursing services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor.
You asked the Plan to pre-approve the requested device. The Plan denied your request. The Plan says the required criteria has 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 indicate that the enrollee performs blood glucose testing at least four times per day, uses insulin with at least three daily injections, or requires frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of the requested device have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient hospital care following an elective total reverse shoulder arthroplasty.
You asked the Plan to pre-approve acute inpatient hospital care. You say that the requested inpatient admission is medically necessary. The Plan denied your request. The Plan says the requested inpatient admission does not meet criteria.
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 pre-approve acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for an inpatient admission are met in this case. Our physician reviewer found the procedure is currently approved as an ambulatory procedure. There is no documentation provided to support the expectation the enrollee will require a greater than 2 midnight stay. 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 pre-approve acute inpatient hospital care following an elective total reverse shoulder arthroplasty.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CPAP device (E0601).

You asked the Plan to pre-approve a CPAP device. You say that the requested item is a medical necessity for you. The Plan denied your request. The Plan says rules for coverage for a CPAP device have not been met.

The Plan must follow Medicare rules. Medicare rules say that enrollees are eligible to re-qualify for a PAP device when the criteria detailed in the Medicare rules section of this letter have been met. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a CPAP device have not been met. Specifically, the case record documents that you failed your initial 12 week trial of a CPAP device. Your use of the CPAP device requires re-qualification. However, the provided medical records do not document a repeat sleep test. Therefore, we decided that the Plan does not have to pre-approve a CPAP device (E0601).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda.

You asked the Plan to pre-approve Keytruda. You say that the medication is 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 a drug or biological only if it is safe and effective and otherwise 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 Keytruda. Our reviewer says that the medication is not medically necessary. Our physician reviewer found the Food and Drug Administration has not stated that the requested drug is indicated for the enrollee's condition. The Medicare approved cancer drug compendia do not contain a supportive citation for the use of the requested drug in the enrollee's clinical situation. No literature from Medicare approved cancer journals were submitted for review. The elements of the coverage criteria 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 Keytruda have not been met. Therefore, we decided that the Plan does not have to pre-approve Keytruda.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a sacroiliac joint injection (27096).

You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that there is insufficient documentation of pain reduction and functional benefit from prior injection to support repeat at this time.

The Plan must follow Medicare rules. Medicare rules say that sacroiliac joint injections are covered if the LCD criteria is 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 requested services are not considered medically reasonable and necessary in this case. There is no documentation of significant pain relief and functional improvement with the previous sacroiliac joint injection. Our physician reviewer found that your condition does not meet Medicare criteria for these 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a sacroiliac joint injection (27096).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Benlysta.
You asked the Plan to pre-approve Benlysta. You say that the medication is 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 a drug or biological only if it is safe
and effective and otherwise 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 Benlysta. Our reviewer says that the
medication is not medically necessary. Our physician reviewer found the Food and Drug Administration has
not stated that the requested drug is indicated for the enrollee's condition. The Medicare approved drug
compendia do not contain a supportive citation for the use of the requested drug in the enrollee's clinical
situation. The elements of the coverage criteria 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 Benlysta have not been met. Therefore, we decided that the Plan does not have
to pre-approve Benlysta.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 18 home health physical therapy visits (G0151).
You asked the Plan to pre-approve home healthy physical therapy services. You say that home health physical
therapy care is medically reasonable and necessary. The Plan denied your request. The Plan says the criteria for
home health services have not been met.
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 home healthy physical therapy services.
Our reviewer says that the requested care is not medically reasonable and necessary. Our physician reviewer
found that the documentation does not support that the member requires additional skilled rehab services to
provide treatment that is medically necessary. The member does not require additional skilled rehab services to
effectively provide treatment, care, and/or services in order to improve the member's condition, perform a
maintenance program to maintain the member's condition and/or prevent deterioration. The member has been
medically stable without any recent exacerbations of chronic medical problems or hospitalizations. The
requested home health services are 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 home healthy physical therapy services have not been met. Therefore, we
decided that the Plan does not have to pre-approve 18 home health physical therapy visits (G0151)
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the facet joint injection services coded as 64494 provided on
April 8, 2021.
You asked the Plan to pay for the facet joint injection services. You say that you would like this claim
reprocessed. The Plan denied your request. The Plan says this has denied correctly based on Medicare rules.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service
exceeds the MUE value cannot be paid when the MAI value is 2.
In this case, the MUE for CPT code 64494 is 1 The MAI value for this code is 2. You billed 2 units of this
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the facet
joint injection services have not been met. Therefore, we decided that the Plan does not have to pay for the
facet joint injection services coded as 64494 provided on April 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genicular nerve ablation.

You asked the Plan to pre-approve genicular nerve ablation. You say that the requested genicular nerve ablation is medically necessary. The Plan denied your request. The Plan says the requested genicular nerve ablation 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 genicular nerve ablation. Our reviewer says that the requested genicular nerve ablation is not medically necessary. Our physician reviewer found radiofrequency ablation (RFA) of the genicular nerves after arthroplasty is the subject of on-going clinical trials and is considered experimental/investigational. Therefore, the request is deemed not medically reasonable or 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 genicular nerve ablation have not been met. Therefore, we decided that the Plan does not have to pre-approve genicular nerve ablation.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing services.
You asked the Plan to pre-approve skilled nursing services. You say that skilled nursing facility services are medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not 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 skilled nursing services. Our reviewer says that daily skilled services are not necessary. The medical records do not show your condition meets a severity of illness or intensity of service criteria that requires an inpatient basis admission 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 skilled nursing services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing services.
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 the intensity of services provided at an IRF. Specifically, you are not shown to be able to tolerate fifteen hours per week of rehabilitative services with regular physician evaluation. 

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 right leg below knee, molded socket, shin, sach foot,
endoskeletal system (CPT code L5301), addition to lower extremity, test socket, below knee (L5620), addition
to lower extremity, below knee, total contact (L5637), addition, endoskeletal system, below knee, ultra-light
material (titanium, carbon fiber or equal) (L5940), addition, endoskeletal system, below knee, alignable system
(L5910), addition to lower extremity, below knee, acrylic socket (L5629), addition to lower extremity, below
knee, flexible inner socket, external frame (L5645), addition to lower extremity, below knee/above knee,
custom fabricated from existing mold or prefabricated, socket insert, silicone gel, elastomeric or equal, for use
with locking mechanism (L5673), addition to lower extremity, below knee/above knee suspension locking
mechanism (shuttle, lanyard or equal), excludes socket insert (L5671), all lower extremity prostheses, flex
walk system or equal (L5981), all endoskeletal lower extremity prosthesis, axial rotation unit, with or without
adjustability (L5984), addition to lower limb prosthesis, vertical shock reducing pylon feature (L5988),
prosthetic sock, multiple ply, below knee, each (L8420), prosthetic shrinker, below knee, each (L8440), and
prosthetic shrinker, below knee, each (L8470).

You asked the Plan to pre-approve the prosthesis and accessories. You say that the items are necessary. The
Plan denied your request. The Plan says the complete right replacement prosthesis is not medically needed. The
Plan states the notes do not show why your current food and ankle cannot be used with a new prosthetic socket.

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 prosthesis and accessories. Our
physician reviewer found the provided records do not sufficiently support that this specific prosthesis is
medically needed. The provided records do not show why your current foot and ankle cannot be used with a
new prosthetic socket which would seem to be a more reasonable solution for you 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 the prosthesis and accessories have not been met. Therefore, we decided that the
Plan does not have to pre-approve the right leg below knee prosthesis and accessories (CPT code(s): L5301,
L5620, L5637, L5940, L5910, L5629, L5645, L5673, L5671, L5981, L5984, L5988, L8420, L8440, and
L8470).
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 admission to a SNF. You say that the requested admission to a SNF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF admission.

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 admission to a SNF. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found based on the documentation provided, the enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. The enrollee appears to be functioning at/near her baseline. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs, as a practical matter, can be provided at a lower level of care. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of admission to a SNF 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vagus Nerve Stimulation (VNS) therapy to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve VNS therapy 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 Vagus Nerve Stimulation (VNS) therapy to be provided by an out-of-network (OON) provider
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) for the enrollee.
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The
Plan denied your request. The Plan says that your request is not medically necessary because the enrollee's
records show that he has already had 2 radiofrequency sessions in this spinal region in the previous 12 months.
The Plan must follow Medicare rules. Medicare rules say that for each covered spinal region no more than two
(2) radiofrequency sessions will be reimbursed per rolling 12 months.
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 requested services are not considered medically reasonable and necessary in this case. The patient already
has had 2 injections during the past 12 months. Our physician reviewer found that the enrollee's condition does
not meet Medicare criteria for RFA.
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 radiofrequency ablation (RFA) for the enrollee.