Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve Dexcom G6 Receiver and supply allowance (CPT code(s): K0553 and K0554).
You asked the Plan to pre-approve the receiver and supplies. You say that the receiver and supplies are necessary. The Plan denied your request. The Plan says that the rules need the record to show that you often change how much drug (insulin) is being taken and the record does not show this.
The Plan must follow Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and necessary for enrollees with diabetes who meet the criteria referenced 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 the receiver and supplies. Our physician reviewer found the data provided does give enough information to conclude that you are adjusting your doses and/or food intake in some way based on the blood glucose levels. 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 receiver and supplies have been met. Therefore, we decided that the Plan has to pre-approve Dexcom G6 Receiver and supply allowance (CPT code(s): K0553 and K0554).
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 Freestyle libre 14-day sensor kit, for the enrollee.
You asked the Plan to pre-approve the sensor. You say that having access to continuous glucose monitoring will allow the enrollee to catch these episodes before they become severe, and also help the enrollee's clinical team with continued adjustments to prevent these episodes. The Plan denied your request. The Plan says the Medicare rules have not been met.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan. We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin three or more times per day or use with an insulin pump.
Based on this information, we decided that Medicare rules for coverage of the sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve Freestyle libre 14-day sensor kit, for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ilumya (J3245).
You asked the Plan to pre-approve Ilumya. You say that the enrollee has tried alternative therapies without adequate results. The Plan denied your request. The Plan says the enrollee has not tried and failed the preferred drugs.
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 Ilumya. Our reviewer says that Ilumya is not medically necessary. Our physician reviewer found based on the provided documentation the enrollee has not tried and failed the required drugs. The reviewer also found that there is no indication that the plan's required drugs would likely be less effective and/or likely have adverse effects for the enrollee. The reviewer found that the step therapy criteria has not been met and therefore the request for Ilumya is not medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Ilumya have not been met. Specifically, the file does not show that the enrollee has tried and failed the required drugs. Therefore, we decided that the Plan does not have to pre-approve Ilumya (J3245).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services beyond October 27, 2021.
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 continued services are not medically necessary.
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 these services. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found you were admitted to the SNF on
October 7, 2021 after hospitalization for a gastrointestinal (GI) bleed. The therapy notes dated October 19,
2021 and October 21, 2021 state you need minimal assistance to walk 10 feet with a rolling walker, sit up, and
stand up. You have no skilled nursing needs. You are at a new level of function and do not require skilled
therapy on a daily basis. As a practical matter, you do not require the necessary services on an inpatient basis at
the SNF 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 these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve continued skilled nursing facility (SNF) services beyond October 27, 2021
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 enrollee needs admission to an IRF. The Plan denied your request. The Plan says criteria for admission to the IRF setting have 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 that 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. Medical
problems are stable. There are no complex nursing or rehabilitation needs. 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 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 a leadless pacemaker.
You asked the Plan to pre-approve a leadless pacemaker. You say that this procedure is medically necessary. The Plan denied your request. The Plan says leadless pacemakers are non-covered when furnished outside of a CMS approved CED study.
The Plan must follow Medicare rules. Medicare rules say that in order for a leadless pacemaker to be covered, they must be performed in a CMS approved study. We looked at the file and Medicare rules. Specifically, the enrollee is not currently enrolled in a CMS approved study. Based on this information, we decided that Medicare rules for coverage of a leadless pacemaker have not been met. Therefore, we decided that the Plan does not have to pre-approve a leadless pacemaker.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a CPAP device (E0601) and accessories provided on September 17, 2020.
You asked the Plan to pay for a CPAP device and accessories. You say that in the past these items have been covered. The Plan denied your request. The Plan says rules for payment have not been met.
The Plan must follow Medicare rules. Medicare rules provide only for rental of CPAP devices and accessories. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a CPAP device and accessories have not been met. Specifically, you have purchased rather than renting the items at issue. Therefore, we decided that the Plan does not have to pay for a CPAP device (E0601) and accessories provided on September 17, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (70450) provided on April 11, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled service.
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 70450 has a bundled relationship with code 70496 and cannot be paid as billed. This code cannot be paid as a separate line item. 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 services (70450) provided on April 11, 2021
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Pneumatic compressor, segmental home model without calibrated gradient pressure (E0651) and Segmental pneumatic appliance for use with pneumatic compressor, full leg (E0667).
You asked the Plan to pre-approve intermittent limb compression device. You say that the items are medically necessary. The Plan denied your request. The Plan says there was no record of 4-week trial of conservative therapy.
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with venous stasis ulcers. 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 intermittent limb compression device. Our reviewer says that the service is not medically necessary. Our physician reviewer found te records, however do not clearly show that you fully exhausted and failed conservative treatment strategies including a basic pump for your condition or had evidence of chronic and severe lymphedema to help justify these devices. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of intermittent limb compression device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Pneumatic compressor, segmental home model without
calibrated gradient pressure (E0651) and Segmental pneumatic appliance for use with pneumatic compressor, full leg (E0667).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the office services (CPT code 99202) to be provided by an out-of-network provider.
You asked the Plan to pre-approve the office services. You say that you want this provider assigned as your primary care physician (PCP). The Plan denied your request. The Plan says this provider is a specialist in the Health Plan; however, the provider is not a contracted PCP.
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 the office services (CPT code 99202) to be provided by an out-of-network provider
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the electric tricycle.
You asked the Plan to pre-approve the electric tricycle. You say that you would like the electric tricycle so you can begin to lose weight for needed upcoming surgery. The Plan denied your request. The Plan says the electric tricycle is not a Medicare-covered item as it is not primarily medical in nature. The Plan states that your treating practitioner has not prescribed this equipment.
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 electric tricycle.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve TENS device, four or more leads, for multiple nerve stimulation (CPT code E0730).
You asked the Plan to pre-approve the TENS device. You say that you have been dealing with back pain for a long period of time due to ataxia. You state the TENS device has been the only method to manage pain. The Plan denied your request. The Plan says the Medicare rules have not been met.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the TENS device have not been met. The information provided shows that you are not enrolled in a clinical trial/study for the TENS device. Therefore, we decided that the
Plan does not have to pre-approve TENS device, four or more leads, for multiple nerve stimulation (CPT code E0730).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a sacroiliac (SI) joint injection.
You asked the Plan to pre-approve SI joint injection. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this injection is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SI joint injection. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee received a bilateral sacroiliac (SI) joint injections on October 7, 2020. A follow-up visit noted greater than 70% pain relief from the injection. The pain is worse with walking or bending over. The enrollee has done physical therapy, exercise, and medication management. Another SI joint injection has been recommended. The enrollee's physician documents that the enrollee's current pain appears to be radicular in nature associated with spinal stenosis and neurogenic claudication. The records do not document that the enrollee reached the 75% threshold for pain relief from the prior injection.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SI joint injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a sacroiliac (SI) joint injection.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of inpatient mental health care from October 28, 2021, forward.
You asked the Plan to pre-approve inpatient mental health care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the records received show that your condition has improved, and you are no longer a threat to yourself or others.
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 care.
Our physician reviewer found the admission does not meet the criteria for continued acute inpatient mental health treatment for the dates in question of October 28, 2021, forward as you were not shown to be a danger to yourself or others. You were not showing any auditory or visual hallucinations and were cooperative/compliant with treatment. You were not showing any aggressive behaviors, or any treatment required for acute threats of safety as you waited placement. 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 care have not been met. Therefore, we decided that the Plan does not have to pre-approve continuation of inpatient mental health care from October 28, 2021, forward.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for periodontal maintenance (D4910) provided on April 15, 2021.
You asked the Plan to waive the deductible for periodontal maintenance. You say that the one-page dental benefits flyer provided to you when you signed up for dental coverage defines the services you received as covered without deductibles or other cost-sharing. The Plan denied your request. The Plan says the correct cost-sharing was applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $150 deductible which applies to out-of-network dental services covered under the enhanced wrap dental benefit. We determined that the Plan policy you appended to your appeal describes benefits in 2015. Plan benefits can change from year to year. According to the Plan's 2021 benefits, the service you asked the Plan to waive the deductible for falls within the enhanced wrap dental benefit. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $150 deductible which applies to out-of-network dental services
covered under the enhanced wrap dental benefit. This cost sharing is a contractual obligation that had not been met at the time periodontal maintenance was received on April 15, 2021. Therefore, we decided that the Plan does not have to waive the deductible for periodontal maintenance (D4910) provided on April 15, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee has finished the current hospital course and they need to remain in the current facility. The Plan denied your request. The Plan says the stay is not medically necessary.
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 there is no documentation provided indicating medical necessity for admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where they are currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.
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 LTACH services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the FoundationOne Liquid CDx test provided to the enrollee on October 19, 2020.
You asked the Plan to pay for the test. You say that this was medically necessary. The Plan denied your request. The Plan says no invoice was provided by the office.
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 pay for the test. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found liquid biopsy is not considered a a standard of care for the treatment of refractory esophageal cancer. Tissue is available for molecular testing and has already been tested for MMR, MSI, HER2, and PD-L1. No rationale for liquid biopsy is provided. The use of FoundationOne Liquid is not reasonable or medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the test have not been met. Therefore, we decided that the Plan does not have to pay for the FoundationOne Liquid CDx test provided to the enrollee on October 19, 2020.