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

We decided that the Plan does not have to pre-approve Keytruda, fosaprepitant, palonosetron, carboplatin, and pemetrexed for the enrollee.

You asked the Plan to pre-approve Keytruda, fosaprepitant, palonosetron, carboplatin, and pemetrexed. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says that the requested regimen is not supported.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. 

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, fosaprepitant, palonosetron, carboplatin, and pemetrexed. Our reviewer says that Keytruda, fosaprepitant, palonosetron, carboplatin, and pemetrexed are not medically reasonable and necessary for the enrollee. The enrollee has Stage IVB non-small cell lung cancer, poorly differentiated adenocarcinoma. The enrollee was treated with palliative carboplatin, paclitaxel and bevacizumab for six cycles, ending on October 13, 2020. A repeat computed tomography (CT) scan on December 10, 2020 demonstrated disease progression and the enrollee was started on nivolumab (Opdivo), until August 19, 2021 with further progression of disease seen on September 2, 2021 with a restaging positron emission tomography (PET) CT. The Food and Drug Administration has not indicated that this regimen is approved for the enrollee's clinical condition. The Medicare approved cancer compendia do not contain a positive citation for this regimen in the enrollee's clinical situation. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of Keytruda, fosaprepitant, palonosetron, carboplatin, and pemetrexed.

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, fosaprepitant, palonosetron, carboplatin, and pemetrexed have not been met. Therefore, we decided that the Plan does not have to pre-approve Keytruda, fosaprepitant, palonosetron, carboplatin, and pemetrexed for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM).
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied
your request. The Plan says the criteria for coverage are not 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 indicates that the enrollee does not adjust insulin
dosing based on results of blood glucose testing. 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 Freestyle Libre continuous glucose monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied
your request. The Plan says the criteria for coverage are not 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 indicates that you do not treat with insulin three
or more times per day or use an insulin pump. 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 continuous glucose monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation system.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied
your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that a power seat elevation feature (E2300) is non-covered.
We looked at the file and Medicare rules. The item at issue is a power seat elevation feature. This item is not
covered by Medicare. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation
system.
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 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 the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve specialist services to be provided by an OON provider.

You asked the Plan to pre-approve specialist services. You say that you would like this approval for this out-of-network
provider. The Plan denied your request. The Plan says there are 113 in-network providers within a 30-
mile radius.

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
specialist services to be provided by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a folding wheeled walker and walker seat attachment.

You asked the Plan to pre-approve a folding wheeled walker and walker seat attachment.. You say that you are not using the items you currently have. The Plan denied your request. The Plan says the documentation shows that you currently have appropriate equipment.

The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. 

The file shows that you have a lightweight wheelchair with leg rests and a walker. Your current lightweight wheelchair with leg rests and walker serves the same purpose as a folding wheeled walker and walker seat attachment. Therefore, we decided that the Plan does not have to pre-approve a folding wheeled walker and walker seat attachment.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the foldable portable Hoyer lift (E1399).

You asked the Plan to pre-approve the foldable portable Hoyer lift. You say that the enrollee is considered total
care and is incontinent. You need the portable Hoyer lift to move the enrollee around and to get him out to the
vehicle for doctor appointments and keep him from deteriorating further. The Plan denied your request. The
Plan says this item is considered to be a sit to stand lift and is not a covered item.

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 the foldable portable Hoyer lift (E1399).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services and a biopsy provided on April 16, 2021,
by an OON provider.

You asked the Plan to pay for physician services and a biopsy. You say that you would like this claim
reprocessed and paid. You say that these services were medically necessary. The Plan denied your request. The
Plan says prior authorization was not obtained by the member's primary care physician. The Plan says that the
referring provider is also out-of-network.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan had network providers
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for physician services and a biopsy provided on April
16, 2021, by an OON provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional pulmonary rehabilitation visits.

You asked the Plan to pre-approve additional pulmonary rehabilitation visits. The Plan denied your request.
The Plan says you had the maximum 72 sessions as covered by Medicare and additional pulmonary
rehabilitation is not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary PR programs
for those with moderate to very severe COPD. There must be a referral from the doctor treating the disease.
The services must be provided in a doctor's office or an outpatient hospital setting. The PR program must
include specific components. Benefits are limited to a maximum of 36 visits, with an additional 36 visits if
medically necessary.

We looked at your request, the file and Medicare rules. Based on this information, we decided that Medicare
rules for coverage of additional pulmonary rehabilitation visits have not been met. Specifically, the record
indicates that you have received 72 total PR visits. Therefore, we decided that the Plan does not have to pre-approve
additional pulmonary rehabilitation visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve diagnostic facet joint injections (64494, 64493).
You asked the Plan to pre-approve diagnostic facet joint injections. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee has had previous successful procedures.
The Plan must follow Medicare rules. Medicare rules say that diagnostic procedures should be performed with the intent that if successful, a radiofrequency ablation (RFA) procedure would be considered the primary treatment goal at the diagnosed level(s). If there is an extended period of time, two years or more, since the last RFA and/or there is a question as to the source of the recurrent pain then diagnostic procedures must be repeated. We looked at the file and Medicare rules. The records do not show that it has been at least two years since the enrollee's previous RFA at the requested level or that there is a question as to the source of the pain. Based on this information, we decided that Medicare rules for coverage of diagnostic facet joint injections have not been met. Therefore, we decided that the Plan does not have to pre-approve diagnostic facet joint injections (64494, 64493).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve spinal surgery.
You asked the Plan to pre-approve spinal surgery. You say that this surgery is medically necessary. The Plan
denied your request. The Plan says the criteria for coverage have not been met.
The Plan follows Medicare rules. Medicare rules say that when conservative therapy (non-surgical medical
management) is unsuccessful after at least 3 to 12 months, depending on the diagnosis, lumbar spinal fusion
may be considered for certain conditions.
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 spinal surgery. Our reviewer says that
the requested service is not medically necessary and reasonable. Our physician reviewer found in this case, the
medical records provided do not show that the patient has had significant conservative measures for low back
pain. More conservative measures are needed.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of spinal surgery have not been met. Therefore, we decided that the Plan does not
have to pre-approve spinal surgery.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 10 additional physical therapy visits.

You asked the Plan to pre-approve 10 additional physical therapy visits. You say that the enrollee would
benefit from continued therapy to improve his current status and improve the outcome following his knee
replacement. You say that further aquatic therapy would be beneficial to his current and future physical
abilities. The Plan denied your request. The Plan says additional visits are not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient
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 10 additional physical therapy visits.
Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent
deterioration of the enrollee's condition. Our physician reviewer found that the patient has had prior therapy,
has been instructed in a home exercise program and is also scheduled for knee surgery on September 13, 2021.
Our reviewer says that the unique skills of a professional therapist are not required to safely and effectively
provide ongoing treatment.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of 10 additional physical therapy visits have not been met. Therefore, we decided
that the Plan does not have to pre-approve 10 additional physical therapy visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprove a therapeutic continuous glucose monitor (CGM).

You asked the Plan to preapprove the CGM. You say that the enrollee requires this device due to hypoglycemic unawareness. The Plan denied your request. The Plan says the enrollee does 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 indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of the CGM have not been met. Therefore, we decided that the Plan does not have to preapprove a therapeutic continuous glucose monitor (CGM).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Cologuard.

You asked the Plan to pre-approve Cologuard. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says you do not meet criteria for the requested services.

The Plan must follow Medicare rules. Medicare rules say that Cologuard is covered when enrollees are between the ages of 50 and 85 years. 

We looked at the file and Medicare rules. Cologuard is covered when enrollees are between the ages of 50 and 85 years. Review of the file does not support that you are between the age of 50 and 85 years old. Based on this information, we decided that Medicare rules for coverage of Cologuard have not been met. Therefore, we decided that the Plan does not have to pre-approve Cologuard.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.

You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee is at a prior level of function.

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 the admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there is no documentation that skilled nursing services are required. The specialized skill, knowledge and judgment of a skilled professional nurse are not required to safely and effectively provide medically necessary and reasonable treatment. Daily skilled services of any kind are not required. Based on the medical records provided, this enrollee does not require the services on an inpatient basis, only in a skilled nursing facility setting. Services in the home with home health care or in a long-term care facility on a part time basis appear appropriate in this case. 

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 admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a glucose monitor external transmitter (A9277).

You asked the Plan to pre-approve the external transmitter. You say that the device should be covered. The Plan denied your request. The Plan says this device doesn't meet the definition of a CGM so it is not covered.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs can be used to make treatment decisions without the need for a stand-alone home blood glucose monitor to confirm testing results. This device is not approved to make treatment decisions therefore, it is not covered.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the external transmitter have not been met. Therefore, we decided that the Plan does not have to pre-approve a glucose monitor external transmitter (A9277).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital care (99223, 99233) provided to the enrollee from July 11, 2020, to July 14, 2020.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the records do not support the services 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.

In this case, the CPT Code Manual definition of the denied codes is:

CPT 99223:

initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission are of high severity.

Physicians typically spend 70 minutes at the bedside and on the patient's hospital floor or unit

CPT 99233:

subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of the 3 key components: A detailed interval history; A detailed examination; Medical decision making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is unstable or has developed a significant complication or a significant new problem. Physicians typically spend 35 minutes at the bedside and on the patient's hospital floor or unit.

We asked our coder 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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer found the medical records provided does not include sufficient documentation to meet requirements of CPT 99223 or 99233; therefore, these procedures cannot be verified. The claim does not meet criteria for reimbursement consideration.

We looked at this coder'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 pay for inpatient hospital care (99223, 99233) provided to the enrollee from July 11, 2020, to July 14, 2020.