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

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says experimental and investigational procedures are not covered by Medicare.
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 the enrollee indicates that the enrollee has chronic lumbar pain and spinal stenosis with neurogenic claudication. The record indicates that the enrollee has multi-factorial pain. The record indicates that imaging has demonstrated multi-level disease with moderate spinal stenosis at L3-L4, the level requested for treatment. The provided record does not document that operative treatment is not required at more than two levels. The record does not indicate that the enrollee has had a failure of six-month non-operative treatment, including physical therapy, directed at the lumbar pathology. 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 the device have not been met. Therefore, we decided that the Plan does not have
to pre-approve the Vertiflex device for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an additional 35 EECP therapy sessions.

You asked the Plan to pre-approve external counterpulsation, per treatment session (G0166). You say that the enrollee would benefit from maintenance EECP therapy. The Plan denied your request. The Plan says it has not been 3 months since the last session and there has not been significant improvement in symptoms.

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 external counterpulsation, per treatment session (G0166). Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there are very limited literature reports of use of a repeat full course EECP therapy in some patients who initially responded but then develop recurrent debilitating angina. However, there are no published indications for regular ongoing and repeated courses of maintenance therapy. Therefore, repeated ongoing EECP with continued weekly maintenance treatment after the recent completion of a full course of therapy in a patient with only Class I-II symptoms, would not be considered medically necessary and does not satisfy the criteria of the applicable Centers for Medicare and Medicaid Services (CMS) NCD for EECP therapy. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of external counterpulsation, per treatment session (G0166) have not been met. Therefore, we decided that the Plan does not have to pre-approve an additional 35 EECP therapy sessions.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued acupuncture services to be rendered by the out-of-network (OON) provider.
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says there are in-network providers available to render the requested services.
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 pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve continued acupuncture services to be rendered by the out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the office visit to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve the office visit. You say that the service is medically necessary. The Plan denied your request. The Plan says the provider is out-of-network.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the office visit to be provided by an out-of-network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychiatric diagnostic and psychological testing evaluations provided on January 22, 2021 by an out-of-network provider.
You asked the Plan to pay for the psychiatric diagnostic evaluation (90791) and psychological testing evaluation services (96130). You say that you were unaware of the need for prior authorization. The Plan denied your request. The Plan says you did not request prior authorization as required.
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 requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the psychiatric diagnostic and psychological testing evaluations provided on January 22, 2021 by an out-of-network provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy to be provided by the requested out-of-network provider.
You asked the Plan to pre-approve physical therapy. The Plan denied your request. The Plan says your plan will only cover out-of-network providers under limited circumstances. While you are a member of our Plan you must use network providers to get your medical care and services. The only exceptions are emergencies, and urgently needed services when the network is not available. There are in-network providers who can treat your same condition; therefore, your request has been denied.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve physical therapy to be provided by the requested out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the presumptive and definitive drug testing services provided on November 25, 2020.
You asked the Plan to pay for the drug testing. You say that this is correctly billed and is medically necessary. The Plan denied your request. The Plan says the POS code reported on this claim is not appropriate.
The Plan must follow Medicare rules. Medicare rules say that for lab services, the POS code must reflect the location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory
directly. The documentation provided does not support that the sample for this testing was taken by the laboratory. As such, the use of POS code 81 is not supported. Therefore, we decided that the Plan does not have to pay for the presumptive and definitive drug testing services provided on November 25, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for extractions (D7140 x4), and alveoloplasty in conjunction with extractions (D7311) provided on February 23, 2021.
You asked the Plan to pay an additional amount for extractions, and alveoloplasty in conjunction with extractions. You say that you were told there would be no charges for these services. The Plan denied your request. The Plan says the copayments were applied correctly.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of extractions, and alveoloplasty in conjunction with extractions have not been met. Specifically, the Plan applied the copayments correctly. Therefore, we decided that the Plan does not have to pay an additional amount for extractions (D7140 x4), and alveoloplasty in conjunction with extractions (D7311) provided on February 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM).
You asked the Plan to pre-approve a therapeutic CGM. You say that this request is medically necessary. The Plan denied your request. The Plan says the coverage criteria for a CGM 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 perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and 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 assesses 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 therapeutic CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM).
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 IRF care is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says rules for IRF care 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 the patient was admitted for surgical repair of a hip fracture after a fall.
Medical problems are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for a intensive, multi-disciplinary rehabilitation program. In conclusion, there is not a reasonable expectation that this patient 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the service is medically necessary. The Plan denied your request. The Plan says the service is 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled nursing or skilled therapy on a daily basis or at an inpatient level in a SNF. 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 care have not been met. Specifically, medically necessary services can be obtained at a lower level of care. This means SNF care is not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve microprocessor control feature, addition to upper limb prosthetic terminal device.
You asked the Plan to pre-approve microprocessor control feature, addition to upper limb prosthetic terminal device. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested item 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 microprocessor control feature, addition to upper limb prosthetic terminal device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has a diagnosis of acquired absence of the left upper limp above the elbow. The enrollee was approved for a replacement prosthesis on May 20, 2021. This approved prosthesis included the code L6880 for electric hand, switch or myoelectric controlled, independently articulating digits, any grasp pattern or combination of grasp patterns, includes motor(s). According to the Joint DME MAC publication Articulating Digit (s) and Prosthetic Hands, Correct Coding, the code L6880 describes a complete terminal device and includes all necessary components.
This L code describes a product that is all-inclusive. Billing of any additional features or functions used to
describe a manufacturer's terminal device is considered unbundling. The code L6880 is comprised of five (5)
articulating digits and the necessary motors. Therefore, the enrollee does not meet criteria for the requested
item.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of microprocessor control feature, addition to upper limb prosthetic terminal
device have not been met. Therefore, we decided that the Plan does not have to pre-approve microprocessor
control feature, addition to upper limb prosthetic terminal device.
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 requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF 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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. 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 special study of the upper or lower extremity (arms or legs) arteries.
You asked the Plan to pre-approve special study of the upper or lower extremity (arms or legs) arteries. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.
The Plan follows Medicare rules. Medicare rules say that bilateral carotid ultrasound testing is only covered for certain indications.
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 special study of the upper or lower
extremity (arms or legs) arteries. Our reviewer says that the documentation does not support that the requested
services are medically reasonable or necessary. Our physician reviewer found the enrollee has reported reduced
arterial flow noted on bedside duplex by podiatrist during an evaluation for an ingrown toenail. There is no
indication that the enrollee had significant abnormality of the carotids to justify this exam due to no abnormal
exam findings or reported symptoms. No dizziness was reported. No evidence of bruits on exam or prior
significant plaque on the carotids to justify repeat testing. Therefore, bilateral carotid ultrasound testing will be
considered not medically necessary based on the provided documentation.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of special study of the upper or lower extremity (arms or legs) arteries have not
been met. Therefore, we decided that the Plan does not have to pre-approve special study of the upper or lower
extremity (arms or legs) arteries.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an interspinous spacer device.
You asked the Plan to pre-approve the requested services. You say that you are having trouble walking. The Plan denied your request. The Plan says it has not been shown to be safe and effective in long-term studies.
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 there is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines. This service is considered experimental and investigational as it is not identified as widely used and generally accepted for the proposed use as reported in nationally recognized peer-reviewed medical literature published. Therefore, the request for Vertiflex Superion interspinous device at L4-5 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 requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve an interspinous spacer device.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the epidural injections to a second level (64484 x 2).
You asked the Plan to pre-approve the epidural injections. You say that the service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary.
The Plan follows Medicare rules. Medicare rules say that it is not expected that a patient would undergo an epidural injection at more than two (2) levels (unilateral or bilateral) on any given date of service. 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 epidural injections. Our reviewer says that the service is not medically necessary. Our physician reviewer found the enrollee is being treated at two levels and has been approved for treatment at the requested levels. The additional second level codes are not appropriate. 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 epidural injections have not been met. Therefore, we decided that the Plan does not have to pre-approve the epidural injections to a second level (64484 x 2).