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

We decided that the Plan does not have to pre-approve Synvisc-One for the enrollee. 
 
You asked the Plan to pre-approve Synvisc-One. The Plan denied your request. The Plan says that the 
information submitted does not meet the Plan's medical necessity guidelines for coverage. 
 
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 Synvisc-One. Our reviewer says that 
Synvisc-One is not medically reasonable and necessary for the enrollee. Our physician reviewer found that the 
enrollee's condition does not meet step therapy criteria for Synvisc-One. The enrollee has not trialed 
viscosupplemental treatments such as Orthovisc and Monovisc. The documentation does not outline 
contraindications or reasons these medications were not considered. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Synvisc-One have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Synvisc-One for the enrollee.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve a MyoPro Motion G Orthotic device (L8702). 
 
You asked the Plan to pre-approve the MyoPro Motion G Orthotic device. You say that the device is medically 
necessary. The Plan denied your request. The Plan says that the MyoPro Motion G Orthotic device is not 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 MyoPro Motion G Orthotic device. 
Our reviewer says that the requested item is considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee suffered a stroke and was treated with physical therapy and bracing with 
insufficient benefit. A MyoPro (myoelectric upper extremity orthotic) device was requested. This device is 
newer in the market, however, prior studies on the technology and recent high quality studies of this technology 
in the setting of stroke-related weakness suggests a measurable benefit of this device at improving overall 
function and safely for the patient. 
 
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 MyoPro Motion G Orthotic device have been met. Therefore, we decided 
that the Plan has to pre-approve a MyoPro Motion G Orthotic device (L8702).  
 
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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for Avastin (J9035).
You asked the Plan to pay for the Avastin. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support the units 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 J9035 is injection, bevacizumab, 10 mg. We asked our coder 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 Avastin. Our reviewer says that CPT code J9035 does not meet criteria for billing or reimbursement consideration. Our reviewer found the visit note documents "at 3.5 mm from the limbus at 1 o'clock, the intravitreal injection of 1.25 mg of Avastin was given. This is the incorrect code to use. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Avastin have not been met. Therefore, we decided that the Plan does not have to pay for Avastin (J9035).
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 IRF admission is medically necessary. The Plan denied your request. The Plan says your needs can be met at a different level of care.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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 you does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at an alternate 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve cervical/thoracic facet joint radiofrequency neurolysis (64633). 
 
You asked the Plan to pre-approve cervical/thoracic facet joint radiofrequency neurolysis. You say that the 
services are necessary. The Plan denied your request. The Plan says that based on the documentation provided, 
coverage criteria has not been met. 
 
he Plan follows Medicare rules. Medicare rules say that the destruction of cervical, thoracic or lumbar 
paravertebral facet joint (median branch) nerves will not be considered medically reasonable and necessary 
under certain circumstances. 
 
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 cervical/thoracic facet joint 
radiofrequency neurolysis. Our reviewer says that the services are medically necessary. Our physician reviewer 
found the enrollee meets the criteria for performance of cervical radiofrequency ablation (RFA) of the medical 
branch block (MBBs). The enrollee has failed conservative therapy. The requested procedure is medically 
reasonable and 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 cervical/thoracic facet joint radiofrequency neurolysis have been met. 
Therefore, we decided that the Plan has to pre-approve cervical/thoracic facet joint radiofrequency neurolysis 
(64633).  
 
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 inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. 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 must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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 records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a skilled nursing facility (SNF) level of care. Ongoing pain medication and other medication management, O2 care, and daily therapy can be provided at a SNF. In this case, the enrollee is mostly minimal assist for functional transfers and activities of daily living (ADL's) and a less intensive, longer duration of therapy will allow for measurable gains to be attained within a reasonable, and predicted period. An IRF intensity is not warranted. 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 pay for an anesthetic professional fee (99100) provided on January 
25, 2020. 
 
You asked the Plan to pay for an anesthetic professional fee. You say that you should be reimbursed for this 
fee. The Plan denied your request. The Plan says this is not supported in the submitted records. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of an anesthetic professional fee have not been met. Although the submitted documentation states  
you were billed for an anesthetic professional service, no records showing an anesthesia service was provided 
have been submitted. Therefore, we decided that the Plan does not have to pay for an anesthetic professional 
fee (99100) provided on January 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient hospital services provided on March 3, 2020.
You asked the Plan to pay for the outpatient hospital services. The Plan denied your request. The Plan says
non-emergent, non-urgent services with out-of-network providers require 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 requested provider in this case is not a network provider with the Plan. 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 outpatient hospital services provided on March 3, 2020.
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 need therapy to increase strength, endurance and 
mobility. You say that you don't feel safe returning home and agree to go to therapy. The Plan denied your 
request. The Plan says the request 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 above. 
 
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 IRF level of therapies are not required given your current level of function. Our 
reviewer says that your rehab needs can be met in a lower intensity 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 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services. 
 
You asked the Plan to pre-approve home health services. 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 must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found the requested home health 
aide services are not reasonable and necessary to the treatment of your illness or injury by the skilled 
professional staff. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve scaling and root planing (D4341) and a crown for tooth 
# 8 (D2790). 
 
You asked the Plan to pre-approve the scaling and root planing and crown. You say that the services are 
medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
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. The Plan covers the scaling 
and root planing and crown when the services are medically necessary and reasonable.  
 
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 scaling and root planing and crown. 
Our reviewer says that the requested scaling and root planing and crown on tooth #8 are not medically 
necessary. Our physician reviewer found given the lack of adequate support for the presence of four or more 
involved teeth in any quadrant the request for CPT code D4341 is not medically necessary or reasonable. There 
has been no supplied documentation that supports the need for replacement of the existing crown on tooth #8. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the scaling and root planing and crown have not been met. Therefore, we 
decided that the Plan does not have to pre-approve scaling and root planing (D4341) and a crown for tooth # 8 
(D2790).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an ECG provided on January 22, 2020.
You asked the Plan to pay for the ECG. The Plan denied your request. The Plan says the Plan does not cover
services provided by out-of-network providers except for emergencies or urgent care while traveling.
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 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 an ECG provided on January 22, 2020.
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 IRF admission is medically necessary. The Plan denied your request. The Plan says the enrollee's needs can be met at a different level of care.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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 enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's needs can be met at an alternate 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 inpatient rehabilitation facility (IRF) admission and services.
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 services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has 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 above. 
 
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 documentation does not support that the complexity of your nursing, medical and 
rehabilitation needs requires an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 
care. Your medical conditions are generally medically stable, and the documentation does not support that you 
have complex medical issues that require acute rehab nursing care, or monitoring by an inpatient physical, 
medical, and rehabilitation (PMR) physician three times per week. While you are reasonably expected to 
benefit from physical therapy (PT) and occupational therapy (OT), the documentation does not support that 
there is need for an intensive therapy program with therapy 3 hours per day, with frequent physician oversight 
and an interdisciplinary approach to rehabilitation 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on February 5, 2020 by a participating chiropractor.
You asked the Plan to pay for the services. You say that you are appealing for reconsideration of the denied charges. The Plan denied your request. The Plan says the service is not covered when it is billed by a chiropractor.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. Review of the file show that you received an office visit that included radiology and physical therapy services from a participating chiropractor. These services are not covered when billed by a chiropractor because your EOC states that the Plan covers only manual manipulation of the spine to correct subluxation. Therefore, we decided that the Plan does not have to pay for the services provided on February 5, 2020 by a participating chiropractor.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Myobloc for the enrollee.
You asked the Plan to pre-approve Myobloc. The Plan denied your request. The Plan says that this is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 Myobloc. Our reviewer says that Myobloc is not medically reasonable and necessary for the enrollee in this case. The enrollee has a history of low back pain. He has undergone multiple epidural steroid injections and right-sided medical branch blocks. He underwent a right-sided lumbar radiofrequency ablation at L3-S1 and has undergone trigger point injections. You have recommended trigger point injections with Myobloc. Botulinum toxin injections for the treatment of myofascial and low back pain lack controlled clinical trials or are still under investigation and are therefore, considered not medically necessary. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for Myobloc. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Myobloc have not been met. Therefore, we decided that the Plan does not have to pre-approve Myobloc for the enrollee.