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

We decided that the Plan does not have to pre-approve compression stockings (A6549).
You asked the Plan to pre-approve the compression stockings. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says compression stockings are not a covered benefit under your contractual policy.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are noncovered because they do not meet the statutory definition of a surgical dressing. Although these items may be appropriate for you, they do not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings (A6549).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Orencia 125mg/mL syringes.
You asked the Plan to pre-approve the Orencia. You say that the enrollee requires this medication. The Plan
denied your request. The Plan says this drug is self-injected and cannot be covered by Medicare Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 Orencia 125mg/mL
syringes.
Benefits for the Orencia 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that the enrollee has ongoing pain and foot
deformity which necessitates the use of orthopedic shoes. The enrollee's conditions put him in the same risk
category for skin breakdown and amputation as diabetics. The requested orthotics are a medical necessity. The
Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.
Records show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace.
Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of
orthotics for the enrollee's condition. Therefore, we decided that the Plan does not have to pre-approve foot
orthotics.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued physical therapy. You asked the Plan to pre-approve continued physical therapy. You say that you need these services to treat your pain. The Plan denied your request. The Plan says the requested services are repetitive in nature. The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 physical therapy. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the records show that you have had  extensive therapy for your condition. The records do not indicate you require the ongoing unique skills of a professional therapist to safely and effectively provide treatment. You have had prior training in a home exercise program. The requested services are not part of a maintenance program and the specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design and/or deliver a program to maintain your current condition or to prevent or slow further deterioration. 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 physical therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve continued physical therapy.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the neuromuscular reeducation (97112 x 4), electrical stimulation (97032 x 2), vasopneumatic device therapy (97016), therapeutic, prophylactic, or diagnostic injections (96372 x 4), unclassified drugs (J3490 x 7), Vitamin B-12 injection (J3420), Pyridoxine 100 mg injections (J3415 x 4), and the Thiamine 100 mg injections (J3411 x 4) provided on December 16, 2019. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says these services are not a covered benefit under the enrollee's contractual policy. 
 
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 services at issue are not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the neuromuscular reeducation (97112 x 4), electrical stimulation  (97032 x 2), vasopneumatic device therapy (97016), therapeutic, prophylactic, or diagnostic injections  (96372 x 4), unclassified drugs (J3490 x 7), Vitamin B-12 injection (J3420), Pyridoxine 100 mg injections (J3415 x 4), and the Thiamine 100 mg injections (J3411 x 4) provided on December 16, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for observation care discharge day management (CPT Code 99217) provided to the enrollee on January 13, 2020.
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your request. The Plan says the Medicare rules have not been met.
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 services have not been met. Another observation service was reported for the same date of service. Therefore, we decided that the Plan does not have to pay for observation care discharge day management (CPT Code 99217) provided to the enrollee on January 13, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that transfer to an LTACH is medically necessary for the enrollee. The Plan denied your request. The Plan says Medicare criteria for transfer to an LTACH are not met. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found based on the documentation provided, the enrollee is currently undergoing treatment at an acute care hospital (ACH) after having suffered a hemorrhagic stroke. The enrollee is not intubated or ventilated. The enrollee has received a feeding tube. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. Medicare transfer criteria are not met.  
 
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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve tooth extractions (D7210) to be provided by an oral surgeon.
You asked the Plan to pre-approve tooth extractions to be provided by an oral surgeon. You say that you need this because you are in a lot of pain. The Plan denied your request. The Plan says this service is not covered when provided by an oral surgeon.
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. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve tooth extractions (D7210) to be provided by an oral surgeon.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (D2750) for tooth #25.
You asked the Plan to pre-approve the crown. You say that the enrollee has existing rot with a huge filling due to an eating disorder and lack of posterior molars. You also say that in order to preserve the tooth, which is very weak and to seal it completely to avoid infection, it needs a crown. The Plan denied your request. The Plan says the x-rays show the filling in the tooth canal does not go all the way to the tip of the root. The Plan also says that placing a crown on tooth #25 in its current state is not recommended and does not meet the Plan's coverage criteria.
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 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 crown. Our reviewer says that the crown is not medically necessary. Our physician reviewer found due to the possible infection resulting from the inadequate root canal filling, the criteria for coverage for a crown restoration for tooth #25 (D2750) have not been met until an adequate root canal filling is done. 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 crown have not been met. Therefore, we decided that the Plan does not have to pre-approve a crown (D2750) for tooth #25.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an MRI of the lumbar spine.
You asked the Plan to pre-approve the lumbar MRI. You say that the enrollee is not likely to benefit from
physical therapy due to his other conditions. Imaging is required in order for him to be seen by pain
management. The Plan denied your request. The Plan says without a trial of physical therapy, advanced
imaging cannot be approved at this time.
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 lumbar MRI. Our reviewer says that
the requested imaging is not shown to be medically reasonable and necessary at this item. Our physician
reviewer found the subjective and objective findings from the recent note did not sufficiently support MRI at
this time. Although he had failed conservative treatments and there was suggestion of a radiculopathy present,
there was insufficient objective evidence of such to support this diagnosis or any other red flag diagnosis to
justify MRI at this time. The straight leg raise test is too subjective to diagnosis radiculopathy alone, and no
other signs were present. Therefore, based on insufficient support from the provided records, this request for
lumbar MRI will be considered 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 the lumbar MRI have not been met. Therefore, we decided that the Plan does
not have to pre-approve an MRI of the lumbar spine.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 testing provided on July 31, 2019.
You asked the Plan to pay for the Guardant360 testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not a covered benefit.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. Review of the file shows that the plan uses Local Coverage Determination, LCD L38168 to support their denial. However, LCD L38168 was not valid for this date of service, therefore, we cannot use L38168 to substantiate our decision. The Guardant360 testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the Guardant360 testing provided on July 31, 2019.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Orthovisc injections.
You asked the Plan to pre-approve Orthovisc injections. You say that the requested Orthovisc injections are medically necessary. The Plan denied your request. The Plan says that the requested Orthovisc injections are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Orthovisc injections. Our reviewer says that the requested Orthovisc injections are medically necessary. Our physician reviewer found this enrollee presents with persistent worsening bilateral knee pain with associated popping. Functional limitations are noted in ambulatory tolerance. She is using a cane for ambulation. Clinical exam findings are consistent with severe bilateral knee osteoarthritis, bone-on-bone in the medial compartments. She has failed to achieve adequate relief with activity modification, ice, home exercise, and corticosteroid injections. Under consideration is a request for a series of 5 Orthovisc injections to the bilateral knees. Evidence based medical peer-reviewed literature supports the use of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. Current evidence based medical guidelines state that medical evidence suggests intra-articular hyaluronic acid injections may relieve osteoarthritic knee pain in some patients. A trial of Orthovisc injections is reasonably indicated for treatment of this enrollee's knee pain given the failure of reasonable and/or comprehensive conservative treatment, worsening pain and functional limitations, and severity of her osteoarthritis. Orthovisc is FDA approved for the treatment of knee osteoarthritis, and supported by Clinical Pharmacology. Therefore, the documentation would support that the Orthovisc injections are medically reasonable and necessary and safe and effective for treatment of this enrollee's severe bilateral knee osteoarthritis. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Orthovisc injections have been met. Therefore, we decided that the Plan has to pre-approve Orthovisc injections.
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Watchman left atrial appendage closure (LAAC).
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says there is
no documentation that a structural heart team has discussed the procedure and collectively determined that it is
appropriate.
The Plan follows Medicare rules. Medicare rules say that a left atrial appendage closure is only covered under
certain medical 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 the requested services. Our physician
reviewer found that the enrollee has a history of smoking, hypertension, coronary artery disease, renal disease,
thyroid disease, diabetes, congestive heart failure and atrial fibrillation treated with ablation. A follow up noted
reports continued normal sinus rhythm and tolerating apixaban. The documentation states the enrollee is
suitable for short term anticoagulation, but not long term anticoagulation due to chronic anemia and recurrent
epistaxis. Hematocrit is reported at 32 and treatment for epistaxis is not documented. The documentation does
not support the enrollee is under the care of a multidisciplinary team including two independent noninterventional
cardiologists. Therefore, the coverage criteria is not met.
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 a Watchman left atrial appendage closure (LAAC).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for acupuncture provided from November 14, 2019 through March 21, 2020 by a non-participating provider. You asked the Plan to pay for acupuncture. You say that the claims should be paid because you have a history of allergy and sinus problems. The Plan denied your request. The Plan says you do not have out-of-network benefits. 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 has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for acupuncture provided from November 14, 2019 through March 21, 2020 by a non-participating provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Entresto.
You asked the Plan to pre-approve Entresto. You say that Entresto is the standard of care. The Plan denied your request. The Plan says Entresto to be taken at home is not covered under the 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 Entresto.
Benefits for Entresto 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 long term acute care hospital (LTACH) services for the
enrollee.
You asked the Plan to pre-approve the LTACH services. You say that transfer to an LTACH is medically
necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our reviewer says that the requested
LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found
the documentation does not support that the enrollee in this case requires services at the LTACH that are not
available at the acute care hospital where he is currently receiving care. There are no required medical services
identified that are available at the LTACH, that are not available at the current health care setting being offered
by the health plan. Consequently, the requested LTACH services are not medically necessary, reasonable, and
appropriate for the diagnosis and condition of 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 the LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve left-sided cervical radiofrequency ablation (RFA) of the facet joints.
You asked the Plan to pre-approve the cervical RFA. You say that this should be allowed to reduce the enrollee's pain. The Plan denied your request. The Plan says the enrollee has only had one MBB. As such, the RFA is not covered.
The Plan must follow Medicare rules. Medicare rules say that RFA of the facet joints is covered when the enrollee has had two MBBs which produced 80% pain relief, or one therapeutic injection that provided 50% relief for at least three months. The documentation only supports that one single diagnostic MBB was provided and that relief lasted fewer than three months. AS such, the criteria for coverage of an RFA have not been met at this time. Therefore, we decided that the Plan does not have to pre-approve left-sided cervical radiofrequency ablation (RFA) of the facet joints.