Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve the implantation of neurostimulator (64568) and the respiratory
sensor electrode insertion (0466T).

You asked the Plan to pre-approve the implantation of neurostimulator electrode (64568) and the respiratory
sensor electrode insertion (0466T). You say that the denial of this treatment is preventing access to valuable
medical treatment that significantly enhance your health and reduce other medical problems in the future. You
say that the requested procedure is medically necessary for your life-threatening condition, and you meet all the
criteria for this procedure. The Plan denied your request. The Plan says that you do not meet the requirements
for a device that stimulates your nerves to treat your sleep issue.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item
or service, then that item or service will be covered when it is medically necessary.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the implantation of neurostimulator
electrode (64568) and the respiratory sensor electrode insertion (0466T). Our reviewer says that the
hypoglossal nerve stimulator is medically necessary, and the patient meets Medicare criteria for the device. Our
physician reviewer found that the member is older than 22, most recent apnea hypopnea index is 25.5, has
documented continuous positive airway pressure (CPAP) intolerance, inadequate treatment with an oral
appliance, body mass index is 30, and very few central apneas. Our reviewer says that the risks and benefits of
the procedure have been discussed and there was no concentric airway collapse on the endoscopy.

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 implantation of neurostimulator electrode (64568) and the respiratory sensor
electrode insertion (0466T) have been met. Therefore, we decided that the Plan has to pre-approve the
implantation of neurostimulator (64568) and the respiratory sensor electrode insertion (0466T).

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: 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. You say that you cannot prick yourself with needles. The Plan denied your request. The Plan says you do not meet the coverage criteria.  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 you use insulin with at least three daily injections. 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: Drugs
Decision: Favorable

 We decided that the Plan has to pre-approve Prolia.  

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says that the step therapy requirement is not met.  

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 these services. Our reviewer says that the services are medically necessary. Our physician reviewer found the enrollee has age-related osteoporosis without current pathological fracture. She has breast cancer and is on an aromatase inhibitor. It is noted that she has significant arthritis and is on Gabapentin. She has not tried and failed the Plan's required drugs, two bisphosphonates (such as alendronate or zoledronic acid); however, the records support that the required drugs would be more likely to have adverse effects. Zoledronic acid is associated with significant skeletal muscle pain. Prolia is reasonable and medically necessary for the enrollee 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 these services have been met. Therefore, we decided that the Plan has to pre-approve Prolia.   

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for the abdominal ultrasound (76700) provided on June 23, 2021. 

 You asked the Plan to pay for the abdominal ultrasound. You say that you would like this claim reprocessed for medical necessity. The Plan denied your request. The Plan says this claim has not been billed with an appropriate modifier as required by Medicare billing rules.  

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 76700 is a column II code to column I code 93975. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the abdominal ultrasound (76700) provided on June 23, 2021.
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 LTACH services are medically necessary for this enrollee and will provide the optimal outcome. The Plan denied your request. The Plan says the criteria for admission to an LTACH are not met. The enrollee is receiving medically necessary acute and/or critical care, and these services have not been denied. The enrollee does not have clinical conditions that cannot be appropriately treated in the current hospital, and there are no issues for which an LTACH would provide a therapeutic advantage.  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 record indicates that the enrollee is improving but still has COVID-19 encephalopathy and requires ongoing acute care services. The enrollee is receiving continued acute care services at the current facility, and these have not been denied. The medical record does not indicate that the enrollee requires services that he 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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve lumbar injections. You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the enrollee does not meet the criteria for coverage.  The Plan must follow Medicare rules. Medicare rules say that epidural steroid injections are only covered under certain medical indications.   Repeat lumbar epidural injections were requested. We looked at the file and Medicare rules. The file shows that the enrollee received lumbar injections in December of 2021. Repeat injections may be considered when sustained improvement of pain lasts for at least three months. Based on this information, we decided that Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve lumbar injections.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve inpatient mental health treatment.  You asked the Plan to pre-approve inpatient mental health treatment. 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 inpatient psychiatric services may be covered if the patient requires active treatment.   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 inpatient mental health treatment. Our reviewer says that the services are not medically necessary. Our physician reviewer found based upon review of the records provided, this enrollee does not meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in question of November 30, 2021 forward and could have been treated in a lesser restrictive setting. The enrollee was not showing any suicidal or homicidal ideation, auditory or visual hallucinations, delusions and was not showing any behaviors or aggression being cooperative. The enrollee was compliant while not showing any acute threats to safety.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient mental health treatment have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient mental health treatment.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve selective catheter placement, vascular embolization, or occlusion, transcatheter occlusion or embolization for tumor destruction, radiopharmaceutical therapy, technetium tc-99m macroaggregated albumin, radiopharmaceutical localization of tumor, and radioelements for brachytherapy to be provided by an OON provider.    You asked the Plan to pre-approve selective catheter placement, vascular embolization, or occlusion, transcatheter occlusion or embolization for tumor destruction, radiopharmaceutical therapy, technetium tc-99m macroaggregated albumin, radiopharmaceutical localization of tumor, and radioelements for brachytherapy 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 selective catheter placement, vascular embolization, or occlusion, transcatheter occlusion or embolization for tumor destruction, radiopharmaceutical therapy, technetium tc-99m macroaggregated albumin, radiopharmaceutical localization of tumor, and radioelements for brachytherapy to be provided by an 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. The Plan denied your request. The Plan says you will not be able to tolerate 3 hours of therapy a day.  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 physician reviewer found that you were admitted to the acute care hospital for the coronavirus, Clostridium difficile colitis and metabolic encephalopathy. The complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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 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 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 is not medically necessary.  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 based on the documentation provided you do not require the intensity of services provided at an IRF. Specifically, you are not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. Your care needs can be met 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 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: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Botox injections.  You asked the Plan to pre-approve Botox injections. You say that previous Botox injection services provided significant relief. You say that the enrollee has ongoing severe symptoms, with significant impact on quality of life. The Plan denied your request. The Plan says the requested Botox injections are not being requested for a medically accepted indication.  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 Botox injections. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found there is no documentation that the Botox injections meet Medicare criteria for medically reasonable and necessary for the enrollee's gastroparesis. According to the Medicare-approved major drug compendia, gastroparesis is not a medically accepted indication for Botox injections. There is no documentation that the Botox injections meet Medicare criteria of safe and effective 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 Botox injections have not been met. Therefore, we decided that the Plan does not have to pre-approve Botox injections.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the insertion of stabilization device (22869 and 22870).  You asked the Plan to pre-approve the insertion of stabilization device (22869 and 22870). You say that you highly recommend this minimally invasive procedure when conservative treatment has failed and is a safer alternative to a laminectomy or spinal fusion. You say that the member has failed more than 6 months of conservative treatment and coverage should be provided under the Medicare Advantage Plan. The Plan denied your request. The Plan says there is no clinical information documenting medical necessity.  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 stabilization device (22869 and 22870). Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that interlaminar spacer devices are experimental. More research is needed to show safety and efficacy.     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 stabilization device (22869 and 22870) have not been met. Therefore, we decided that the Plan does not have to pre-approve the insertion of stabilization device (22869 and 22870).
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 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 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 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: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Nexium 20mg capsules.  You asked the Plan to pre-approve Nexium. You say that Nexium is medically necessary. The Plan denied your request. The Plan says this drug is not eligible for coverage under the Part B medical benefit.    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 Nexium 20mg capsules.   Benefits for Nexium 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 Nexletol.

You asked the Plan to pre-approve Nexletol. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug is not a covered benefit.

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 Nexletol.

Benefits for Nexletol 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: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the cervical spine x-ray rendered on September 8, 2021.  You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 72052 is not separately payable.  The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well.  The provider submitted a claim for procedure codes 72052 (cervical spine x-ray, 6 or more views) and 72082 (entire spine x-ray). Code 72052 is a column II code with a modifier indicator of 1 when billed with column I code 72082. Code 72052 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the cervical spine x-ray rendered on September 8, 2021.