Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve stem cell therapy for bilateral knee and right hip (CPT code(s): 20999, 38232, and 0232T).
You asked the Plan to pre-approve the services. You say that you are afraid you will not survive hip and knee surgery due to previous history with not coming out of anesthesia. The Plan denied your request. The Plan says requested services are non-coverable because there is not enough research to show that stem cell therapy is proven to be safe and effective.
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 items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is limited published peer-reviewed literature that shows the request to be an effective and/or safe treatment for osteoarthritis. Detailed documentation is not evident regarding trial and failure of recent, reasonable and comprehensive less invasive conservative care measures. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines. Therefore, the request for stem cell therapy for bilateral knee and right hip (CPT codes: 20999, 38232, and 0232T) 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve stem cell therapy for bilateral knee and right hip (CPT code(s): 20999, 38232, and 0232T).
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 you are appealing this denial. The Plan denied your request. The Plan says the denial of authorization for IRF service is correct.
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 your nursing, medical, and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that you 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve MRI, any joint of lower extremity; without contrast material (CPT code 73721).
You asked the Plan to pre-approve the MRI. You say that your right knee is so painful that you can barely walk, and you need an MRI to find out what is causing it. The Plan denied your request. The Plan says your medical notes state you have pain for three (3) months, but no recent x-rays or trial of physical therapy.
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. Our physician reviewer found you experienced difficulty getting up from a seated position and have had increased pain since then. You have used ice and ibuprofen with some improvement. There is no report of knee instability. No plain films have been performed and she has not been seen by your orthopedic surgeon. The medical records do not demonstrate the medical necessity or reasonableness of obtaining and MRI in this clinical scenario. The elements of the coverage rue are not satisfied. The requested service cannot be recommended 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 MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve MRI, any joint of lower extremity; without contrast material (CPT code 73721).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve PCD (CPT code E0675), for the enrollee.
You asked the Plan to pre-approve the PCD. You say that the PCD is necessary. 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 PCD have not been met. Review of the records does not show a diagnosis of peripheral artery disease. Therefore, the PCD is not approved. The Medicare rules say that, "a PCD coded as E0675 is used in the treatment of peripheral arterial disease. Claims for E0675 will be denied as not reasonable and necessary." Therefore, we decided that the Plan does not have to pre-approve PCD (CPT code E0675), for the enrollee.
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 enrollee has had an adverse reaction to the second COVID vaccine, and her needs have risen beyond what the skilled nursing facility can provide. The Plan denied your request. The Plan says the enrollee's needs are being met in the current nursing facility. There is no reason for transfer to a hospital 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 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 dizziness and bradycardia and was discharged to skilled nursing on 3/26/21. Medical problems are stable. There are no complex nursing or rehabilitation needs. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Special Supplemental Benefits for the Chronically Ill.
You asked the Plan to pre-approve the services. You say that the services are needed. The Plan denied your request. The Plan says you do not meet any of the criteria for the supplemental benefits.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the Plan rules. There was communication from the plan to validate about chronic conditions and you reported that you suffer from skin psoriasis, cholesterol, high blood pressure, and sleep apnea. Therefore, we decided that the Plan does not have to pre-approve Special Supplemental Benefits for the Chronically Ill.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a computerized tomography (CT) scan of the thorax.
You asked the Plan to pre-approve a CT scan. 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 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 a CT scan. Our reviewer says that the documentation does not support that the requested CT scan is medically reasonable or necessary. Our physician reviewer found the enrollee has intermittent flank/back pain radiating to the upper abdomen for one month. Pain is relieved with rest and aggravated by movement. The records did not show significant objective physical findings suggestive of an abdominal or pelvic etiology of the enrollee's symptoms, which were suggestive of a spinal etiology. Also, there was no clear report of full efforts made with using more conservative physical therapy or medications or other imaging such as ultrasound to identify the etiology. No red flags were noted to justify this imaging at this time. Therefore, the enrollee does not meet criteria for the requested services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a computerized tomography (CT) scan of the thorax.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve durable medical equipment to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve durable medical equipment. You say that you would like approval for this. The Plan denied your request. The Plan says there are in-network providers available for these 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 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 durable medical equipment to be provided by an out of network (OON) provider.
Please contact the Plan for a list of in-network providers available for these services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a genicular nerve block for the enrollee.
You asked the Plan to pre-approve the block. You say that this is medically necessary. The Plan denied your request. The Plan says this is considered experimental and investigational.
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 block. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this treatment is considered experimental and investigational. The approach is the subject of ongoing clinical trials. Therefore, the procedures are considered 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 block have not been met. Therefore, we decided that the Plan does not have to pre-approve a genicular nerve block for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the use of the i-FACTOR allograft during an approved lumbar spinal fusion procedure.
You asked the Plan to pre-approve the i-FACTOR allograft. You say that the requested services should be approved due to medical necessity. The Plan denied your request. The Plan says all requested services have been approved aside from the use of the specific requested allograft. There is not sufficient evidence to support its use in this case.
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 i-FACTOR allograft. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the requested type of allograft remains experimental for use in spinal surgery. More research is necessary to support the safety and efficacy of this product. 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 i-FACTOR allograft have not been met. Therefore, we decided that the Plan does not have to pre-approve the use of the i-FACTOR allograft during an approved lumbar spinal fusion procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pontic and two retainer crowns.
You asked the Plan to pre-approve the pontic and retainer crowns. You say that you would like to appeal these services. The Plan denied your request. The Plan says these services are not covered under your plan.
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 a pontic and two retainer crowns.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve three additional pontic/retainer crowns (D6740, D6245).
You asked the Plan to pre-approve three additional crowns. You say that the Plan is using 2020's coverage criteria which is not applicable to 2021 coverage. The Plan denied your request. The Plan says 2021's coverage criteria states that crowns are limited to 10 units per year.
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 are in excess of those covered under this benefit. The Plan has approved the maximum of 10 units of pontic/retainer crowns, out of the 13 requested. Therefore, we decided that the Plan does not have to pre-approve three additional pontic/retainer crowns (D6740, D6245).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office consultation (99243) and medical eye examination (92012) to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the office consultation and eye exam. You say that the enrollee is living out of the area and would like services from the OON provider. The Plan denied your request. The Plan says they have been unable to verify a new address with the enrollee and the enrollee does not meet OON criteria for coverage of the 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 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 an office consultatio
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips.
You asked the Plan to pre-approve the additional trips. You say that rides to dialysis are needed. The Plan denied your request. The Plan says the maximum number of trips has been utilized for the year.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 40 one-way trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve occlusal orthotic appliance (CPT code D7880).
You asked the Plan to pre-approve the occlusal orthotic appliance. You say that you need a more appropriate nightguard the current one you have is old, wearing out and is the incorrect design for TMJ condition. The Plan denied your request. The Plan says this code is not covered by Medicare.
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 occlusal orthotic appliance have not been met. This code is not covered by Medicare. Therefore, it is not covered by the health plan. The rules say that oral occlusal appliances used to treat TMJ disorders are coded D7880 - occlusal orthotic appliance. Claims for these devices should not be submitted to the DME MACs. Therefore, we decided that the Plan does not have to pre-approve occlusal orthotic appliance (CPT code D7880).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a combo sit and stand system for the enrollee.
You asked the Plan to pre-approve the system. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a combo sit and stand system for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex Superion device (22869, 22870).
You asked the Plan to pre-approve the Vertiflex device. You say that included with this letter is the clinical documentation which supports these clinical findings and medical necessity for the procedure. The Plan denied your request. The Plan says this device is experimental and investigational. More studies are needed to show Vertiflex is safe and effective. The enrollee is not receiving this device as part of a Medicare covered clinical trial.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The rules also say that experimental and investigational devices are not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Vertiflex device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex Superion device (22869, 22870).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a blood pressure machine for the enrollee.
You asked the Plan to pre-approve the machine. You say that this is medically necessary. The Plan denied your request. The Plan says this is not primarily medical in nature.
The Plan must follow Medicare rules. The rules say that Medicare covers home blood pressure monitors only for enrollees who are on home dialysis, or those who meet the criteria for white coat hypertension and require ABPM to confirm a diagnosis of hypertension. The records do not show that this monitor is requested in the setting of home dialysis services, or that this request is for evaluation of suspected white coat hypertension. Although monitoring blood pressure in the home may be appropriate in this case, neither Medicare nor the Plan provides coverage of this item in this situation. Therefore, we decided that the Plan does not have to pre-approve a blood pressure machine for the enrollee.
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 this will help relieve daily foot pain. 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 you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.