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

We decided that the Plan does not have to pay forthe skilled nursing services provided from October 22, 2019 to November 3, 2019.You asked the Plan to pay forthe skilled nursing services. The Plandenied your request. The Plan says the enrollee's clinical condition did not require skilled nursing care as an inpatient and did not require skilled care for her mobility functions. The Plan also says that the enrollee was medically stable.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 pay for the skilled nursing services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on 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 the skilled nursing services have not been met.Therefore, we decided that the Plan does not have to pay forthe skilled nursing services provided from October 22, 2019 to November 3, 2019
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve spinal bone growth stimulator (E0748).You asked the Plan to pre-approve spinal bone growth stimulator. You say that you still have more surgery to undergo. The doctors say the bone stimulator can take your healing from a year down to 5 or 6 months and that what they don't want to approve. Yet everything has been approved.The Plan denied your request. The Plan says the medically necessary criteria has not been met for the spinal bone growth stimulator.The Plan must follow Medicare rules. The rules say that an electrical bone stimulator is covered for nonunion of long bone fractures. Nonunion of long bone fractures is considered to exist only when serial radiographs have confirmed that fracture healing has ceased for 3 or more months prior to starting treatment with the electrical bone growth stimulator. Serial radiographs must include a minimum of 2 sets of radiographs separated by a minimum of 90 days. 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 spinal bone growth stimulator. Our reviewer says that this enrollee does not meet the Medicare coverage criteria. Our physician reviewer found this enrollee was one-week status post single level spinal fusion at the time of this request, with no evidence of failed fusion. There is no history of previously failed spinal fusion at the same site. A search of PubMed was conducted to see if a reasonable exception to Medicare criteria was warranted. However, there is no published medical evidence to support that bone growth stimulation improved spinal fusion in patients recovering from non-Hodgkin's lymphoma. Medicare coverage indications have not been met for a spinal bone growth stimulator We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of spinal bone growth stimulator have not been met.Therefore, we decided that the Plan does not have to pre-approve spinal bone growth stimulator (E0748).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the presumptive drug testing (screening) provided on September 30, 2019.
You asked the Plan to pay for the presumptive drug testing. You say that this testing is supported and should be covered. The Plan denied your request. The Plan says the order does not indicate that a screening/presumptive test was requested.
The Plan must follow Medicare rules. Medicare rules say that lab testing may be covered when ordered by a treating provider. In this case, the provider ordered the custom panel. The documentation shows that the custom panel for this provider does not include a presumptive screening. Therefore, we decided that the Plan does not have to pay for the presumptive drug testing (screening) provided on September 30, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an occlusal orthotic device (D7880).You asked the Plan to pre-approvethe dental item. You say that the enrollee was seen in regards totreatment of the temporomandibular joint (TMJ). You say that the occlusal orthotic device is medical in nature, not dental. You also say that the occlusal orthotic device is listed in the contract between you and the medical group with a set case rate.The Plan denied your request. The Plan says the occlusal orthotic device is considered dental in nature. The Plan also says that the contract between you and the medical group does not constitute coverage through the Medicare Advantage plan.Medicare generally does not cover dental services. The Plan follows the same rules.The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement of the enrollee's teeth or the structures directly supporting the enrollee's teeth. These are dental services that are not covered or paid for by Medicare. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested occlusal orthotic device is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approvean occlusal orthotic device (D7880).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forthe skilled nursing services provided from September 9, 2019 to October 8, 2019.You asked the Plan to pay forthe skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act.The Plan denied your request. The Plan says that you did not require daily skilled nursing and/or daily skilledrehabilitation services.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 pay for the skilled nursing services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on 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 the skilled nursing services have not been met.Therefore, we decided that the Plan does not have to pay forthe skilled nursing services provided from September 9, 2019 to October 8, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvethe Yutiq eye implant.You asked the Planto pre-approvethe implant. You say that this is medically necessary.The Plandenied your request. The Plansaysthis is an off-label use of this implant.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 implant. Our reviewer says that the requested implant is not considered medically reasonable and necessary in this case. Our physician reviewer found the use of the Yutiq fluocinolone implant would be considered experimental for the enrollee's disease. There are case reports of intravitreal fluocinolone implant for macular edema associated with retinal vein occlusion, however, the standard of care is the use of intravitreal anti-VEGF medication. There is no evidence in the medical literature that treatment with intravitreal fluocinolone would be more beneficial than the standard of care. Furthermore, the potential for side-effects is much higher with the use of intravitreal steroids than with the standard of care. The health plan is justified to deny coverage for the Yutiq implant in this case.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the implant have not been met.Therefore, we decided that the Plandoes not haveto pre-approvethe Yutiq eye implant.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided to the enrollee on June 26, 2019 and billed under codes 80156, 80157, 80177, 80201, 80162, 80159 and 80173
You asked the Plan to pay for drug testing provided to the enrollee. You say that this claim should be paid. The Plan denied your request. The Plan says while codes G0483 and 80307 will be paid, there is insufficient physician documentation to support the billing of codes 80156, 80157, 80177, 80201, 80162, 80159 and 80173.
The Plan must follow Medicare rules. Medicare has specific coverage criteria for definitive drug testing. Medicare rules say that physicians and providers must produce medical records showing why the lab services provided were medically necessary. In this case, there were insufficient records provided to show the results of this testing would be used to determine a diagnosis or determine a treatment strategy for disease or illness present in the enrollee at the time of service.
This testing is not covered for screening purposes and when multiple tests are done at one time. The physician order provided was insufficient in identifying the need for the codes denied. Therefore, we decided that the Plan does not have to pay for drug testing provided to the enrollee on June 26, 2019 and billed under codes 80156, 80157, 80177, 80201, 80162, 80159 and 80173.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group two power wheelchair (K0842) and accessories (E0955, E1007, E1012, E1028, E2311).
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says he requested wheelchair exceeds the enrollee's needs.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the requested wheelchair and accessories are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documented upper limb severe weakness or incoordination. The enrollee is not noted to have an inability to utilize a lesser device such as a lightweight manual wheelchair, standard manual wheelchair, or a walker. Therefore, this request is not medically necessary. We looked at this physician's review, the file, and Medicare rules. Our reviewer found that the wheelchair itself is not medically reasonable and necessary, and does not Medicare coverage criteria. The accessories contain coverage provisions that they cannot be covered if the standard criteria for a power wheelchair is not met. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pre-approve a group two power wheelchair (K0842) and accessories (E0955, E1007, E1012, E1028, E2311).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a sleep study for the enrollee.You asked the Plan to pre-approve the study. You say that this is medically necessary.The Plan denied your request. The Plan says this is not a standard of care.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 study. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found an attended sleep study for the purpose of titrating the MAD does not appear to be medically necessary. Such a titration would require careful coordination between the prescribing dentist and the sleep facility staff, and the records do not demonstrate that this is planned or available. Such a procedure is not considered the current standard of care for MAD.The standard of care is for assessing effectiveness of the MAD settings using home monitoring, such as overnight oximetry, and improvement in symptoms. A home sleep study could be done to assess the efficacy of a given advancement 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 study have not been met.Therefore, we decided that the Plan does not have to pre-approve a sleep study for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve paraverterbral facet joint injections for the enrollee.
You asked the Plan to pre-approve the injections. You say that this is medically necessary. The Plan denied your request. The Plan says there is no documentation of a failure of conservative treatment.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the injections. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation of conservative therapy, such as physical therapy. The first set of diagnostic blocks produced only 70% pain relief, which is below the threshold for a positive block. Therefore, the request 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 the injections have not been met. Therefore, we decided that the Plan does not have to pre-approve paraverterbral facet joint injections for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Magnetic Resonance Angiography (MRA) of the head.
You asked the Plan to pre-approve MRA. You say that you are appealing with records. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because the enrollee had normal test results in the past and there is no new clinical information to support this test.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve MRA. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested MRA. Our physician reviewer found the enrollee has had a previous Magnetic Resonance Imaging (MRI) and Magnetic Resonance Angiogram (MRA) which were normal. The documentation does not support a significant change in the enrollee's condition. Her physical examination was normal. The documentation does not support that the requested MRA is medically reasonable and necessary for the enrollee at this time. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of MRA have not been met. Therefore, we decided that the Plan does not have to pre-approve Magnetic Resonance Angiography (MRA) of the head.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve endovenous ablation for enrollee.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 services are not medically necessary.The Plan must follow Medicare rules. Medicare rules say that endovenous ablation is 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has numerous etiologies with respect to leg pain including a history of spinal stenosis and is on chronic pain medication. She also has a history of peripheral artery disease severe enough that it precludes the use of compression stockings. Furthermore, the degree of reflux in the greater saphenous veins bilaterally is not particularly severe. The requested endovenous ablation does not meet the criteria for coverage and 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 these services have not been met.Therefore, we decided that the Plan does not have to pre-approve endovenous ablation for enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the lumbar spine.You asked the Plan to pre-approve these services. You say that the services are medically necessary.The Plan denied your request. The Plan says the services are not medically necessary.The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee is noted to have chronic back pain. There is no evidence of new injury, worsening symptoms or abnormal examination findings. As such, the requested CT of the lumbar spine is not shown to be currently medically necessary or reasonable.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 a computed tomography (CT) scan of the lumbar spine.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a spinal stabilization procedure for the enrollee.
You asked the Plan to pre-approve the requested services. You say that the spacer would provide significant clinical and quality of life benefits for the enrollee. The Plan denied your request. The Plan says there is no clinical indications for the requested technology
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 requested services. Our physician reviewer found that the requested device is considered experimental. More research is needed to determine the efficacy of the procedure. Therefore, the requested service 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 have not been met. Therefore, we decided that the Plan does not have to pre-approve a spinal stabilization procedure for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex spacer for enrollee.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 services are 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has back pain. The requested Vertiflex spacer is considered experimental in nature, as more research is needed to show its efficacy. The services are therefore not reasonable or medically necessary at this time.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 a Vertiflex spacer for enrollee.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve magnetic resonance imaging (MRI) services.
You asked the Plan to pre-approve the MRI services. You say that the records provided support the need for the requested MRI. The Plan denied your request. The Plan says that there is an approval for the same study, or a similar study, that is still in effect. The Plan says that the clinical information provided does not describe the results of this prior imaging. The Plan says that the guidelines for coverage do not support additional imaging without knowing the outcome of the prior approval.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the MRI services. Our reviewer says that the requested MRI is medically reasonable and necessary. Our physician reviewer found the enrollee has a history of back pain and back surgery. Following a recent fall, the enrollee is noted to have increased pain, subjective numbness and objective sensory loss. An MRI has been requested to further evaluate these signs and symptoms, and the documentation supports the medical necessity of this service. 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 MRI services have been met. Therefore, we decided that the Plan has to pre-approve magnetic resonance imaging (MRI) services.
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.