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

We decided that the Plan does not have to pre-approve Privigen (J1459), 1 gram/kilogram weekly x 4 weeks then every other week.
You asked the Plan to pre-approve Privigen. You say that this drug is medically necessary for the enrollee. The Plan denied your request. The Plan says the provided documentation does not meet the criteria for coverage.
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 Privigen. Our reviewer says that the requested dosing for Privigen is not medically necessary. Our physician reviewer found the proposed treatment regimen in this case is not supported by any of the Medicare-approved major drug compendia. Therefore, the reviewer found that the requested dosage of Privigen is 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 Privigen have not been met. Specifically, the record shows that the requested dosage of 1 gram/kilogram weekly x 4 weeks then every other week is not supported by any of the Medicare-approved major drug compendia. Therefore, we decided that the Plan does not have to pre-approve Privigen (J1459), 1 gram/kilogram weekly x 4 weeks then every other week.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an out-of-network referral for a sleep apnea oral appliance.
You asked the Plan to pre-approve the referral. You say that this provider specializes in oral appliance therapy for obstructive sleep apnea. The Plan denied your request. The Plan says there are equally qualified in-network providers who can provide this service.
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 an out-of-network referral for a sleep apnea oral appliance.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc-One (J7325), 48 MG/6 mL, in right knee once every 6 months as needed.
You asked the Plan to pre-approve Synvisc-One. You say that the requested drug is medically necessary. The Plan denied your request. The Plan says the enrollee has not tried and failed the preferred drugs, Orthovisc and Monovisc.
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 Synvisc-One. Our reviewer says that Synvisc-One is not medically necessary. Our physician reviewer found the provided documentation does not indicate that the enrollee has trialed viscosupplemental treatments such as Orthovisc and Monovisc. The reviewer found that the documentation does not outline contraindications or reasons these medications were not considered. Without the support of the documentation, Synvisc-One is not approved, as step criteria have not been met. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Synvisc-One have not been met. Specifically, the file shows that the enrollee has not tried and failed the required drugs. Therefore, we decided that the Plan does not have to pre-approve Synvisc-One (J7325), 48 MG/6 mL, in right knee once every 6 months as needed.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve neuro-oncology services to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve OON services. You say that you have seen this doctor since you were 5 years old. The Plan denied your request. The Plan says there are providers within the network that are able to provide care.
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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve neuro-oncology services to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ophthalmology office visits to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve ophthalmology office visits. You say that the requested provider is the only one that can treat the enrollee's diagnosis. The Plan denied your request. The Plan says this is available in-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 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 ophthalmology office visits to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet joint radiofrequency ablation services for neck pain.
You asked the Plan to pre-approve facet joint radiofrequency ablation services. You say that this procedure is medically necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met.
The Plan must follow Medicare rules. Medicare rules say that radiofrequency ablation services are medically necessary for patients who have had at least two medically reasonable MBBs with each providing a consistent minimum of 80% pain relief. We looked at the file and Medicare rules. In this case, the medical documentation only supports one previous MBB as having been performed. Based on this information, we decided that Medicare rules for coverage of facet joint radiofrequency ablation services have not been met. Therefore, we decided that the Plan does not have to pre-approve facet joint radiofrequency ablation services for neck pain.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the computed tomography (CT) abdomen and pelvis (74177).
You asked the Plan to pre-approve the CT scan. You say that the medical records provided will show proof of medical necessity. The Plan denied your request. The Plan says medical necessity cannot be established for the requested service.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. In this case, it was confirmed that the Plan requested medical records from the provider and none was received. Based on this information, we decided that Medicare rules for coverage of the CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve the computed tomography (CT) abdomen and pelvis (74177).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee on June 9, 2020, to June 13, 2020.
You asked the Plan to pay for the services. You say that the DRG adjustment should be reconsidered. The Plan denied your request. The Plan says the DRG was updated in this case, as the diagnosis of acute respiratory failure with hypoxia, unspecified with hypoxia or hypercapnia is unsupported by the records.
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 . 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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our physician reviewer found there is no documentation provided indicating that J96.01 acute respiratory failure with hypoxia was a valid diagnosis. The review has determined that the hospital did not use the correct DRG and diagnosis for this admission. 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 inpatient hospital services provided to the enrollee on June 9, 2020, to June 13, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable


We decided that the Plan does not have to pay for inpatient hospital services billed with DRG 853 and provided 
on May 15, 2020, through June 1, 2020. 

You asked the Plan to pay for the inpatient hospital services. You say that you would like reconsideration 
because the documentation supports the billed DRG. The Plan denied your request. The Plan says the 
documentation supports an admission for further evaluation and treatment of acute parotitis sialadenitis. 
 
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 a primary diagnosis of Sepsis due to Methicillin 
resistant Staphylococcus aureus (A41.02). 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 hospital services. Our reviewer says that the review has determined that the documentation did not 
support the billing of DRG 853 with the primary diagnosis of A41.02. Our physician reviewer found the 
enrollee with a history of vascular dementia, hypertension, and chronic kidney disease was evaluated and 
treated in the emergency department for parotitis sialadenitis. On presentation her vital signs were stable, and 
her White Blood Cell count was elevated to 15T. She had no clinical or laboratory evidence of sepsis.  
 
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 inpatient hospital services billed with DRG 853 and provided on May 15, 2020, through June 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a consultation and extractions to be provided by an oral surgeon.
You asked the Plan to pre-approve the consultation and extractions. The Plan denied your request. The Plan says dental services are only covered when they are performed by a participating general dentist. The Plan also says that dental services performed by an oral surgeon are not covered.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered when they are received by anyone other than a participating general dentist. Therefore, we decided that the Plan does not have to pre-approve a consultation and extractions to be provided by an oral surgeon.
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 the device will better help control diabetes. The Plan denied your request. The Plan says the enrollee does not meet 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 the enrollee 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of anterior segment aqueous drainage 
device (0191T). 
 
You asked the Plan to pre-approve the insertion of anterior segment aqueous drainage device. You say that this 
procedure is medically reasonable and necessary. The Plan denied your request. The Plan says the coverage 
criteria have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that aqueous drainage devices are medically 
reasonable and necessary for the treatment of adults with mild or moderate open-angle glaucoma and a cataract 
when the individual is currently being treated with an ocular hypotensive medication. 
 
We looked at the file and Medicare rules. In this case, the documentation does not support that the enrollee is 
currently on hypotensive medication. Based on this information, we decided that Medicare rules for coverage 
of the insertion of anterior segment aqueous drainage device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the insertion of anterior segment aqueous drainage device (0191T).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an OmniSeq Insight Panel test. 
 
You asked the Plan to pre-approve an OmniSeq Insight Panel test. You say that the requested test is medically 
necessary and is supported by the article and records provided. The Plan denied your request. The Plan says the 
Omniseq Insight Panel would be unlikely to impact therapeutic decision making in your clinical management 
and is not considered medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that molecular pathology procedures may be eligible for 
coverage when results of the testing directly impact treatment or management of the Medicare beneficiary. 
 
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 an OmniSeq Insight Panel test. Our 
reviewer says that the criteria for coverage have not been met. Our physician reviewer found the available 
documentation does not demonstrate that OmniSeq Insight Panel testing will directly impact treatment or 
management of the enrollee in this case. Additionally, it has not been shown that the number of genes in the 
OmniSeq Insight Panel is reasonable and necessary to obtain the necessary information for therapeutic decision 
making. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an OmniSeq Insight Panel test have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an OmniSeq Insight Panel test.
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 enrollee needs to be monitored by a 
team of physicians on a daily basis. The enrollee's needs cannot be met at a lower level of care The Plan denied 
your request. The Plan says based on Medicare guidelines, the requested LTACH services do not meet the 
requirements for approval. 
 
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 that as LTACHs and acute care hospitals (ACHs) are licensed to provide the same 
level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the 
current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to 
a lower level of care for any ongoing long term care needs. 

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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a microprocessor knee and K3 foot. 
 
You asked the Plan to pre-approve a microprocessor knee and K3 foot. You say that the documentation 
provided supports the need for the items in dispute. The Plan denied your request. The Plan says the items in 
dispute do not meet the Medicare criteria a reasonable and 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 a microprocessor knee and K3 foot. Our 
reviewer says that a microprocessor knee and K3 foot are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the requested items exceed the enrollee's medical need as the enrollee 
is to unload the left leg and has a flexion contracture of the knee. Therefore, the documentation does not 
support that this enrollee is a level K3 ambulator. There is also no evidence why a mechanical knee could not 
be used over a microprocessor. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a microprocessor knee and K3 foot have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a microprocessor knee and K3 foot.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or 
occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. 
There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve neurology office visits to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve neurology office visits. You say that this provider is at the same practice as 
your cardiologist. The Plan denied your request. The Plan says this is available in-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 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 
neurology office visits to be provided by an out-of-network (OON) provider.