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

 
We decided that the Plan has to pre-approve attendant control. We decided that the Plan does not have to pre-
approve push handles, foot plate covers, and padded torso support.   
You asked the Plan to pre-approve attendant control (E2331), push handles (K0108), foot plate covers 
(K0108), and padded torso support (K0108).. You say that the services are necessary. The Plan says that based 
on the documentation provided, coverage criteria have not been met. 
 
We decided that the Plan has to pre-approve attendant control.  
 
The Plan follows Medicare rules. Medicare rules say that power wheelchair accessories are covered when 
specific criteria are met.  
 
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 attendant control. Our reviewer says 
that the services are medically necessary. Our physician reviewer found the enrollee is unable to operate the 
wheelchair. The attendant control is 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 attendant control have been met. Therefore, we decided that the Plan has to pre-
approve attendant control.  
 
We also decided that the Plan does not have to pre-approve push handles, foot plate covers, and padded 
torso support. 
 
The Plan follows Medicare rules. Medicare rules say that power wheelchair accessories are covered when 
specific criteria are met.  
 
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 push handles, foot plate covers, and 
padded torso support. Our reviewer says that the services are not medically necessary. Our physician reviewer 
found the expanded control for the enrollee is not medically necessary. The push handles do not serve a 
medical purpose. The documentation does not provide indications for the expanded foot plate or cover. Seat 
and back cushions are all inclusive. Separate billing is not covered per A52504. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of push handles, foot plate covers, and padded torso support have not been met. 
Therefore, we decided that the Plan does not have to pre-approve push handles, foot plate covers, and padded 
torso support. 
 
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 pay for pneumatic compression devices (E0675, E0673) provided on July 14, 2022.

You asked the Plan to pay for pneumatic compression devices. You say that the items at issue were a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment for durable medical equipment have not been met.

The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home.

The items at issue in this appeal were provided for use outside of the home. Although these items may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pay for pneumatic compression devices (E0675, E0673) provided on July 14, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that the enrollee would like reconsideration because the services are medically necessary. The Plan denied your request. The Plan says an IRF admission is not medically necessary.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that the enrollee's medical problems are stable and there are no complex nursing or rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Lymphacare brand pneumatic compression device (E0651, E0667).

You asked the Plan to pre-approve the device. You say that the enrollee would face obstacles that would impair healing if forced to use the in-network provider. The Plan denied your request. The Plan says there is no urgent or emergent condition or need for specialized services.

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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the provided records do not adequately document how the features of the Lymphacare brand are specifically necessary for this particular patient to avoid an adverse medical outcome and that all other in-network brands would be incapable of meeting the patient's 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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Lymphacare brand pneumatic compression device (E0651, E0667).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the placement of a CardioMEMS device (33289).

You asked the Plan to pre-approve a CardioMEMS device. You say that the requested service is a 
medical necessity for the enrollee. The Plan denied your request. The Plan says the requested 
service is experimental/investigational.

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 CardioMEMS 
device. Our reviewer says that the requested service is not considered medically reasonable and 
necessary in this case. Our physician reviewer found that there remains a dearth of randomized, 
blinded clinical studies examining long-term clinical outcomes establishing the value of CardioMEMS in patient management.

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 CardioMEMS device have not been met. Therefore, we decided that the Plan does not have to pre-approve the placement of a CardioMEMS device (33289).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve iris prosthesis and insertion (C1839, 0616T).

You asked the Plan to pre-approve iris prosthesis and insertion. You say that you disagree with the denial. The Plan denied your request. The Plan says the service is experimental, investigational, or unproven, and is not covered.

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 iris prosthesis and insertion. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the record indicates that the enrollee has oculocutaneous albinism and aniridia. There is insufficient literature to support the medical necessity of the requested service in the enrollee's clinical condition.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of iris prosthesis and insertion have not been met. Therefore, we decided that the Plan does not have to pre-approve iris prosthesis and insertion (C1839, 0616T).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an epidural steroid injection (64483, 64484).

You asked the Plan to pre-approve an epidural steroid injection. 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 follows Medicare rules. Medicare rules say that epidural steroid injection (ESI) will be considered medically reasonable and necessary when specific criteria are met.

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 epidural steroid injection. Our reviewer says that the services are not medically necessary. Our physician reviewer found the documentation does not reveal evidence of 50% sustained improvement in pain relief and/or function from baseline for at least 3 months.

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 epidural steroid injection have not been met. Therefore, we decided that the Plan does not have to pre-approve an epidural steroid injection (64483, 64484).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from August 31, 2021, to September 3, 2021.

You asked the Plan to pay for the acute inpatient hospital care. You say that an inpatient admission was medically reasonable and necessary in this case. The Plan denied your request. The Plan says the enrollee had no documentation of complications related to an ambulatory surgical procedure, complex postoperative course, or need for treatment that could not be appropriately provided in an ambulatory setting. The Plan also says evaluation, treatment, and monitoring in a lower level of care, such as observation, may have been an option.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.

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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the provided notes revealed the enrollee underwent the procedure without complication. Our reviewer also found that post-operative monitoring revealed stable vitals, tolerated physical therapy, and pain managed without an expectation that the enrollee would require hospital services that would likely have crossed 2 midnights at the time of admission.

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 acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided from August 31, 2021, to September 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve office visits (99204, 99214) with an oncologist to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve office visits. You say that your oncologist is no longer with the medical group. The Plan denied your request. The Plan says medical necessity services must be done at an in-network level by a contracted provider. An in-network provider is available.

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 office visits (99204, 99214) with an oncologist 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 Freestyle Libre Kit 2 Sensor.

You asked the Plan to pre-approve the CGM. You say that the CGM is necessary. The Plan denied your request. The Plan says the CGM is not covered for enrollee's not on insulin.

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 show that the enrollee uses insulin 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 pre-approve Freestyle Libre Kit 2 Sensor.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that you need an IRF admission because you have a lot of bone and tissue damage, wear a hip brace, and have a wound vacuum. The Plan denied your request. The Plan says criteria for admission 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 while you may need physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve an IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says the requested IRF services do not meet the 
requirements for approval.

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 while the medical record supports a need 
for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. 
Medically necessary care can be provided in a different level of care.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve an IRF admission and services.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve a Zilretta injection (J3304).

You asked the Plan to pre-approve the Zilretta injection. You say that you have been getting this injection every 3 and a half months for your knee, so you did not have to go through the knee replacement. You also say that you switched to this insurance plan so you would continue with this service, and do not understand why it has been denied. The Plan denied your request. The Plan says that this request does not meet the criteria for coverage.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved 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 the Zilretta injection. Our physician reviewer found that you have a diagnosis of osteoarthritis of the knees. The requested drug is being used for its current Food and Drug labelled indication. Our reviewer found that the FDA has not restricted its use to a single time. The elements of the coverage criteria are satisfied. Our physician reviewer also found that the requested service is recommended.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Zilretta injection have been met. Therefore, we decided that the Plan has to pre-approve a Zilretta injection (J3304).

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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that you cannot walk around or get up the stairs. You need physical and occupational therapy in order the be able to regain the independent lifestyle and are still recuperating from your wounds due to a fall prior to open heart surgery. The Plan denied your request. The Plan says the request is not medically necessary, the services you need can be provided safely in other settings, for example, a skilled nursing facility.

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 your medical problems are stable and there are no complex nursing or rehabilitation needs. There is no documented need for intensive rehabilitation services and medically necessary care can be provided in a different level of care.


We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital services provided on August 10, 2021 to August 18, 2021, at the Diagnosis Related Group (DRG) originally billed.

You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that secondary diagnosis, N17.0, acute kidney failure with tubular necrosis, is supported by evidence and documentation in the medical record for the enrollee's admission. You also say that DRG 219 is the correct DRG assignment for this admission. The Plan denied your request. The Plan says sufficient supporting documentation was not found within the medical record to validate this diagnosis based on clinical criteria.

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, N17.0, defined as Acute renal failure with tubular necrosis. 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 at the DRG originally billed. Our reviewer says that the submitted DRG is not supported. Our physician reviewer found although acute on chronic kidney injury is supported in the documentation following the surgery, confirmation testing for tubular necrosis was not present in the records to justify using the specific diagnosis code, N17.0 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 the inpatient hospital services provided on August 10, 2021 to August 18, 2021, at the Diagnosis Related Group (DRG) originally billed.