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

 We decided that the Plan does not have to pre-approve the insertion of a Vertiflex device (22869, 22870).  You asked the Plan to pre-approve the insertion of a Vertiflex device. You say that this is medically necessary. The Plan denied your request. The Plan says this has not been proven effective.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the insertion of a Vertiflex device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental. More research is needed to show it is safe and effective.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the insertion of a Vertiflex device have not been met. Therefore, we decided that the Plan does not have to pre-approve the insertion of a Vertiflex device (22869, 22870).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and supplies  You asked the Plan to pre-approve a CGM and supplies. You say that these items are medically necessary. The Plan denied your request. The Plan says that the documentation fails to indicate that you use insulin 3 or more times a day.  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 use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a CGM and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and supplies
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve follow-up visit to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve follow-up visit. You say that these services are medically necessary. The Plan denied your request. The Plan says there are in-network providers available to provide the care you need.  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 follow-up visit to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652, E0667) for the enrollee.  You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says there is an absence of detailed measurements before and after a trial of conservative treatment.  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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee does not meet criteria for the requested device as there has not been a four week trial of either E0650 or E0651, and criteria for E0650 or E0651 have not been met due to absence of detailed measurements before and after a trial of conservative treatment. The enrollee does not have unique characteristics that would indicate the segmented pump over a standard pump.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (E0652, E0667) for the enrollee.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve four (4) direct skilled nursing services of a RN in the home health or hospice setting, each 15 minutes (CPT code G0299), for the enrollee.  You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your request. The Plan says the services are not necessary.  The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our physician reviewer found there is no documentation that skilled nursing services are required to effectively provide treatment, care, and/or services in order to improve the enrollee's condition, or to establish/perform a maintenance program to maintain the enrollee's condition and/or prevent deterioration. Records do not document any acute or unstable medical conditions or changes in medication or treatment which would necessitate any further skilled nursing visits beyond what have already been approved. Records do not include any documentation from the enrollee's medical provider indicating additional home health nursing services 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 the services have not been met. Therefore, we decided that the Plan does not have to pre-approve four (4) direct skilled nursing services of a RN in the home health or hospice setting, each 15 minutes (CPT code G0299), for the enrollee.
Appeal type: Imaging
Decision: Favorable

 We decided that the Plan has to pre-approve CT colonography, diagnostic, including image postprocessing; with contrast material(s) including non-contrast images, if performed (CPT code 74262), for the enrollee  You asked the Plan to pre-approve the CT colonography. You say that the service is medically necessary. The Plan denied your request. The Plan says that the service is not necessary.  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 CT colonography. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found the documentation in the case file supports that CT colonography is medically reasonable and necessary for the enrollee 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 CT colonography have been met. Therefore, we decided that the Plan has to pre-approve CT colonography, diagnostic, including image postprocessing; with contrast material(s) including non-contrast images, if performed (CPT code 74262), for the enrollee   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 the MyoPro G Orthotic Device (L8702).  You asked the Plan to pre-approve the MyoPro G Orthotic Device. You say that you would like reconsideration because the requested equipment is medically necessary. The Plan denied your request. The Plan says the documentation does not cite the specific failed modalities.  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 MyoPro G Orthotic Device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the MyoPro is not known to be effective, based on scientific evidence, professional standards, and expert opinion, in improving health outcomes in stroke patients. The MyoPro is not in widespread use based on scientific evidence. There is insufficient evidence in the literature that the MyoPro Orthosis will improve the long-term outcomes for this member, improve hemiparetic arm function, or be safe for long term use. There is insufficient evidence in the literature that this device will increase participation in bimanual activities.  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 MyoPro G Orthotic Device have not been met. Therefore, we decided that the Plan does not have to pre-approve the MyoPro G Orthotic Device (L8702).
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve five (5) direct skilled nursing services of a registered nurse (RN) in the home health or hospice setting, each 15 minutes (CPT code G0299), for the enrollee.  You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your request. The Plan says the records show that six (6) nursing visits have previously been approved to help the enrollee. The Plan states there have been no recent changes to the enrollee's treatment plan or their medications, the enrollee's medical condition has not changed recently, the enrollee has caregivers available to help manage their treatment as needed, and the enrollee has not reported chest pain. The Plan states an occupational therapist is also making visits to the enrollee's home and their records do not support the need for a skilled nurse to make more visits.  The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our physician reviewer found there is no documentation that skilled nursing services are required to effectively provide treatment, care, and/or services in order to improve the enrollee's condition, or to establish/perform a maintenance program to maintain the patient's condition and/or prevent deterioration. Records do not document any acute or unstable medical conditions or changes in medication or treatment which would necessitate any further skilled nursing visits beyond what have already been approved. Records do not document any information from the enrollee's medical provider which indicates that further home health nursing services are required.  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 five (5) direct skilled nursing services of a registered nurse (RN) in the home health or hospice setting, each 15 minutes (CPT code G0299), for the enrollee.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve continuation of direct skilled nursing services of a RN in the home health or hospice setting, each 15 minutes (CPT code G0299).  You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan denied your request. The Plan says the services are not medically necessary.  The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our physician reviewer found there is no documentation that additional skilled nursing services beyond what has been approved by the health plan are required to effectively provide treatment, care, and/or services in order to improve the enrollee's condition, or to establish/perform a maintenance program to maintain your condition and/or prevent deterioration. Records indicate your wound is much improved and almost closed. Records do not document any acute or unstable medical conditions or changes in medication or treatment which would necessitate any further skilled nursing visits beyond what have already been approved.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pre-approve continuation of direct skilled nursing services of a RN in the home health or hospice setting, each 15 minutes (CPT code G0299).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the foot insert (CPT code L3010).

You asked the Plan to pre-approve the foot insert. You say that your foot disease is really painful and feel the foot/shoe insert is medically necessary. The Plan denied your request. The Plan says you do not have documented diabetic foot disease.

Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve the foot insert (CPT code L3010).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the home ventilator (CPT code E0466).  You asked the Plan to pre-approve the home ventilator. You say that this is to be used for the treatment of COPD with chronic respiratory failure. The Plan denied your request. The Plan says the request for a home mechanical ventilator set in pressure support ventilation (PSV) mode that could be delivered by bilevel positive airway pressure (BiPAP) is not covered.  The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD.  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 home ventilator. Our physician reviewer found a home ventilator is not medically necessary. You have severe COPD with chronic hypercarbic respiratory failure. You may benefit from BiPAP at night. Certain BiPAP devices can provide the average volume assured pressure support (AVAPS) mode of support that has been ordered. Medicare does not cover a home ventilator when used as BiPAP. The denial of the ventilator is upheld.  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 home ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve the home ventilator (CPT code E0466).
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 requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does not meet criteria.  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 enrollee appears to be gradually improving but still requires additional short-term acute care services until the enrollee is more stable. There are no services at the LTACH that the enrollee requires that are not already available and covered at the current facility.  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: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the inpatient hospital care provided from November 20, 2020, through November 30, 2020, billed with secondary diagnosis code G93.41.  You asked the Plan to pay for the inpatient services as billed. You say that this was correctly billed and should be paid at the reported DRG. The Plan denied your request. The Plan says the DRG is incorrect as an unsupported secondary diagnosis was billed.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes.    In this case, you billed the inpatient services provided with secondary diagnosis code G93.41, defined as metabolic encephalopathy. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the inpatient services as billed. Our reviewer says that the documentation does not support the use of secondary diagnosis code G93.41 Our physician reviewer found while encephalopathy was documented on the progress note from 11/30/2020, other provider documentation was unclear and/or inconsistent regarding this condition. The history and physical documentation included physical exam findings of alert and oriented times 3 with normal affect. Subsequent documentation consistently recorded neurological status as alert and oriented to person, place, time and situation with appropriate mood, behavior and affect. The documentation evidence from the records available for review was unclear, incomplete, and conflicting for encephalopathy.   We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for the inpatient hospital care provided from November 20, 2020, through November 30, 2020, billed with secondary diagnosis code G93.41.
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 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 the enrollee does require physical therapy and occupational therapy services but based on the medical records provided the enrollee does not require an intensive inpatient rehabilitation therapy program. Care at the skilled nursing facility level appears to be 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 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.