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

 We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).  You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says there are no skilled nursing or skilled therapy needs that can only be provided on an inpatient basis.  The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. You do not require skilled nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care.  You asked the Plan to pre-approve continued SNF care. You say that the requested continuation of SNF care is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for continued SNF care.  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 continued SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found based on the medical records provided there is no documentation that the enrollee requires skilled nursing services, i.e., the specialized skill, knowledge and judgment of a skilled professional nurse are not required to safely and effectively provide medically necessary and reasonable treatment. Based on the medical records provided there is no documentation this enrollee requires skilled therapy services. Based on the medical records provided there is no documentation that daily skilled services are required. Based on the medical records provided there is no documentation that this enrollee requires nursing or therapy services on an inpatient basis, only in a skilled nursing facility setting.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre device and supplies (K0554, K0553).  You asked the Plan to pre-approve a Freestyle Libre device and supplies. You say that the requested items are a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage for the requested items 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 with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a Freestyle Libre device and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre device and supplies (K0554, K0553).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xolair.  You asked the Plan to pre-approve Xolair. The Plan denied your request. The Plan says the enrollee has not tried a high-dose inhaled steroid and long-acting beta agonist inhaler.   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 Xolair. Our physician reviewer found that the record indicates the enrollee has severe persistent asthma. The requested medication is a new start. The Plan requires a trial of a high-dose inhaled steroid and long-acting beta agonist inhaler before they will approve the requested drug. The provided records do not indicate that the enrollee has tried and failed the plan's preferred step one alternatives. The record does not indicate that the enrollee has a contraindication to or would have an adverse effect from the plan's preferred step one alternative. The elements of the coverage criteria are not satisfied.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Xolair have not been met. Therefore, we decided that the Plan does not have to pre-approve Xolair.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve continued inpatient psychiatric care from February 1, 2022, forward.  You asked the Plan to pre-approve continued inpatient psychiatric care. You say that you need additional care in this setting. The Plan denied your request. The Plan says as of January 31, 2022, you no longer meet the criteria for coverage of psychiatric care at the inpatient level. Your condition has improved, and you can be stepped down to a less restrictive level of care.  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 continued inpatient psychiatric care. Our reviewer says that the health plan's denial of continued psychiatric care at the inpatient level appears appropriate in this case. Our physician reviewer found that you were involuntarily admitted to the acute inpatient psychiatric hospitalization on January 20, 2022, with Bipolar Disorder Type I, Most Recent Episode Manic Versus Schizoaffective Disorder Bipolar Type. Based upon a review of the records provided, it was not expected that you would improve in a reasonable period of time for the dates in question as you did not have suicidal or homicidal ideation noted and denied any auditory or visual hallucinations. You were compliant with treatment while not showing any acute threats to safety. It did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the dates in question as you did not have dangerousness to herself or others but was compliant with her treatment. It did not appear that active treatment was taking place beyond the date in question. It did not appear that the services were reasonably expected to improve your condition or for the purpose of diagnosis beyond the date in question. Based upon a review of the records provided, you do not meet the criteria for continued acute inpatient mental health treatment for the dates in question of February 1, 2022, forward.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued inpatient psychiatric care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued inpatient psychiatric care from February 1, 2022, forward.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the targeted case management (T1017) rendered by the out-
of-network (OON) provider on September 9, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network
provider, without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The provider in this case is not a network provider with the Plan. The Plan had network providers available
who could have provided the service at issue in this appeal.
The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for
this service. Therefore, we decided that the Plan does not have to pay for the targeted case management
(T1017) rendered by the out-of-network (OON) provider on September 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the combination sit to stand frame/table system, any size
including pediatric, with seat lift feature, with or without wheels (CPT code E0637), for the enrollee.
You asked the Plan to pre-approve the item. You say that the enrollee requires standing frame to maintain bone
density and prevent fracture. The Plan denied your request. The Plan says Medicare criteria for medical
equipment does not cover a standing frame/table. The Plan states a standing frame/table is not for a medical
problem and makes it easier to stand.
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 item have not been met. You asked for a standing frame/table
because of the enrollee's problems standing without support. Medicare criteria for medical equipment do not
cover this. A standing frame/table is not for a medical problem and makes it easier to stand. Neither Medicare
nor the enrollee's health plan covers this. Therefore, the request is not approved. Therefore, we decided that the
Plan does not have to pre-approve the combination sit to stand frame/table system, any size including pediatric,
with seat lift feature, with or without wheels (CPT code E0637), for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Invokana.  You asked the Plan to pre-approve Invokana. You say that this is medically necessary. The Plan denied your request. The Plan says coverage of this medication is the responsibility of the enrollee's prescription drug plan.  The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Invokana.   Benefits for Invokana may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the drug testing coded G0480 provided on February 3, 2021.  You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable as billed.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.  In this case, the CPT Code Manual definition of code G0480 is drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 1-7 drug class(es), including metabolite(s) if performed.  We find that CPT code G0480 is not supported in the medical record. Specifically, the place of service on the CMS-1500 form line 24B must reflect the location of the enrollee when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, place of service 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting, place of service 11. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing coded G0480 provided on February 3, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve K3 microprocessor components for a lower limb prosthesis (L5848, L5845, L5828, L5856).  You asked the Plan to pre-approve the K3 microprocessor components. You say that the microprocessor knee is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.  The Plan follows Medicare rules. Medicare rules say that coverage is extended only if there is sufficient clinical documentation of functional need for the technologic or design feature of a given type of knee.  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 K3 microprocessor components. Our reviewer says that the requested features are not medically necessary. Our physician reviewer found while the documentation notes that the patient requires a microprocessor knee for it's advanced features including step and stumble recovery, there is no evidence that the patient is unable to safely and effectively meet his functional needs with a standard mechanical knee.       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 K3 microprocessor components have not been met. Therefore, we decided that the Plan does not have to pre-approve K3 microprocessor components for a lower limb prosthesis (L5848, L5845, L5828, L5856).
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.  You asked the Plan to pre-approve SNF services. You say that the enrollee is making progress. You say that there is not proper care for the enrollee at home. You say that the enrollee needs help with her toileting, walking, and getting food. The Plan denied your request. The Plan says the enrollee does not meet the requirements for coverage of SNF care. The Plan says that the enrollee's condition is stable and there are no complex daily skilled needs.  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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral medications, had stable vital signs, and had clear lungs. The enrollee received physical therapy and occupational therapy. The enrollee was at a moderate to maximal assist level with transfers. The enrollee required varying assist with activities of daily living. There are no identifiable current skilled nursing service needs. There are identifiable current skilled therapy service needs, but they are not required on a daily basis. The enrollee does not meet the severity of illness or intensity of service criteria for an inpatient basis in a SNF setting.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Eemt tablets.  You asked the Plan to pre-approve Eemt tablets. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says Eemt tablets are not covered under the enrollee's Medicare Part B benefit.  The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Eemt tablets.   Benefits for Eemt tablets may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve continued inpatient psychiatric care from January 21, 2022, forward.  You asked the Plan to pre-approve continued inpatient psychiatric care. You say that you need additional inpatient psychiatric care. The Plan denied your request. The Plan says as of January 21, 2022, you no longer meet the criteria for continued psychiatric care at the inpatient level. You may be stepped down to a less intensive level of care.  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 continued inpatient psychiatric care. Our reviewer says that the health plan's denial of continued psychiatric services at the inpatient level appears appropriate in this case. Our physician reviewer found that you were admitted to the acute inpatient psychiatric hospitalization on January 11, 2022, with Schizoaffective Disorder Bipolar Type. Based upon a review of the provided records, it was not expected that you would improve in a reasonable period of time beyond the dates in question as you were not showing any dangerousness to self or others, auditory or visual hallucinations, and you were without aggressive behaviors while not showing any acute threats of safety. It did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the dates in question as he did not have any suicidal or homicidal thoughts, auditory or visual hallucinations or abnormal behaviors. It did not appear that active treatment was taking place beyond the date in question. It did not appear that the services for the dates in question were reasonably expected or medically necessary to improve your condition or for the purpose of diagnosis. Based upon review of the records provided, you do not meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in question of January 21, 2022, forward and could have been treated in a lesser restrictive setting.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued inpatient psychiatric care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued inpatient psychiatric care from January 21, 2022, forward.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a portable ventilator for the enrollee.  You asked the Plan to pre-approve the ventilator. You say that this is medically necessary. The Plan denied your request. The Plan says the request for a home mechanical ventilator set in average volume-assured pressure support (AVAPS) 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 ventilator. Our reviewer says that the requested ventilator is not medically reasonable or necessary. Our physician reviewer found the enrollee was admitted with acute respiratory failure in January this year, due to pneumonia. Laboratory studies suggested acute on chronic C02 retention. Spirometry was consistent with severe restrictive disease, no obstruction. The PaCO2 improved on BiPAP. The enrollee does not have chronic obstructive pulmonary disease, neuromuscular disease, or thoracic restrictive disease. There is no arterial blood gas done while the enrollee is stable as an outpatient to document persistent C02 retention. If the enrollee does have chronic C02 retention, the appropriate treatment is BiPAP. Medicare does not cover a home ventilator when used as BiPAP.  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 ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a portable ventilator for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Kerendia tablets.  You asked the Plan to pre-approve Kerendia tablets. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says Kerendia tablets are not covered under the enrollee's Medicare Part B benefit.  The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Kerendia tablets.   Benefits for Kerendia tablets may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.