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

We decided that the Plan does not have to pre-approve the Superion interspinous spacer for the enrollee.
You asked the Plan to pre-approve the spacer. You say that this is medically necessary. The Plan denied your
request. The Plan says a review of the current medical literature indicates that this service 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 spacer. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found the device is experimental. More research is needed to show safety and efficacy.
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 spacer have not been met. Therefore, we decided that the Plan does not have
to pre-approve the Superion interspinous spacer for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a yearly consultation to be provided by an out-of-network
(OON) provider.
You asked the Plan to pre-approve a yearly consultation. You say that you would like the plan to reconsider
their denial. The Plan denied your request. The Plan says the requested services can be provided by a network
provider.
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
a yearly consultation to be provided by an out-of-network (OON) provider.
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 enrollee does not meet criteria for IRF admission.
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 enrollee does not meet criteria for IRF admission. 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 was admitted for left sided weakness. Medical problems are stable. There are no identified problems that need inpatient medical management. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, in an intensive rehabilitation therapy program. The medical record supports a need for physical and occupational therapy but it does not support a need for an intensive rehabilitation therapy program. There is not a reasonable expectation that this enrollee 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelaparoscopic anti-reflux surgery (43284).You asked the Plan to pre-approvelaparoscopic anti-reflux surgery. You say that the denial of the LINX procedure is unwarranted and unsupported by the patient's current medical status, current peer review literature and is inconsistent with currently accepted medical practice.The Plan denied your request. The Plan says the requested service is not medically necessary under Medicare guidelines.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 laparoscopic anti-reflux surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found  the esophagram showed no spontaneous nor provoked gastroesophageal reflux, no PH study was supplied to demonstrate correlation of enrollee's symptoms with reflux events, LES tone and function was normal and does not warrant surgical augmentation and endoscopy identified "non-severe" GERD-related injury (Barrett's changes were not found per histology on the second EGD) to necessitate a surgical anti-reflux procedure. As such, LINX may not be expected to alleviate much of the symptoms that the enrollee may attribute to acid reflux. Accordingly, the medical necessity nor coverage criteria for the proposed service under review is not demonstrated by available records.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of laparoscopic anti-reflux surgery have not been met.Therefore, we decided that the Plan does not have to pre-approvelaparoscopic anti-reflux surgery (43284).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forlab services (81493) provided to the enrollee on May 7, 2020.You asked the Plan to pay forthis service. You say that this claim should be paid.The Plan denied your request. The Plan says this testing is not covered by Medicare. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. Medicare does not cover cardiovascular risk assessment panels. Medicare rules for coverage of this service have not been met.Therefore, we decided that the Plan does not have to pay forlab services (81493) provided to the enrollee on May 7, 2020
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CT scan, heart, without contrast material, with quantitative evaluation of coronary calcium (CPT Code 75571).
You asked the Plan to pre-approve the CT scan. You say that the CT scan is necessary. The Plan denied your request. The Plan says the CT scan is not 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 the CT scan. Our physician reviewer found CT cardiac calcium score is not a covered test in this instance for reasons outlined in the denial. 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 CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve CT scan, heart, without contrast material, with quantitative evaluation of coronary calcium (CPT Code 75571).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a neurosurgery office consult to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve a neurosurgery office consult. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are neither emergent nor urgent to seek out-of-network care. The Plan says there are equally qualified in-network neurosurgeon's available to you that can provide the services you are requesting.
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 a neurosurgery office consult to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea power wheelchair and accessories to be provided by an out-of-network provider.You asked the Plan to pre-approvea power wheelchair and accessories. You say that there is not a vendor in the area that can provide the services needed.The Plan denied your request. The Plan says the power wheelchair and accessories can be provided in network.Medicare rules say that plans can require enrollees toget 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-approvea power wheelchair and accessories to be provided by an out-of-network provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approveduplex scan of the lower extremity arteries or arterialbypass grafts; completed bilateral study.You asked the Plan to pre-approveduplex scan of the lower extremity arteries or arterialbypass grafts; completed bilateral study. 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 duplex scans of thelower extremity arteries or arterialbypass graftsare only covered for certain indications.We asked our physician reviewer to carefully review the case file and applythe relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve duplex scan of the lower extremity arteries or arterialbypass grafts; completed bilateral study. 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 diagnosed peripheral artery disease. Recent physical findings showed no edema to the legs/feet, no varicosities, and normal symmetric pedalpulses. No abnormal ankle brachial index or lower extremity pulse oximetry was documented. The provided documentation does not clearly show objective signs suggestive of arterial occlusion connected to presenting symptoms to justify this test. Therefore, the enrollee dos 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 duplex scan of the lower extremity arteries or arterialbypass grafts; completed bilateral study have not been met. Therefore, we decided that the Plan does not have to pre-approveduplex scan of the lower extremity arteries or arterial bypass grafts; completed bilateral study
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acupuncture treatment to be rendered by the out of network (OON) provider.
You asked the Plan to pre-approve this service. 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 your care.
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 service at issue in this appeal. We found no exception that would require the Plan to pre-approve this service. Therefore, we decided that the Plan does not have to pre-approve acupuncture treatment to be rendered by the out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay fora comprehensive panel of influenza diagnostic testing.You asked the Plan to pay forthis testing. You say that this claim should be paid.The Plan denied your request. The Plan says this testing is used when more limited panels would not be medically appropriate (e.g., patient critically ill, etc.). Use is restricted to when more limited panels would not be medically appropriate (e.g. patientcritically ill, etc.)The Plan states that this is not a COVID-19 test. This is not an emergency test.The Plan states that respiratory infectious agent detection, CPT code 87633 (12-25 targets) is non-covered by Medicare and excluded from coverage. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. Medicare has specific coverage criteria for this type of testing. In this case the testing reported on the claim is excluded from coverage by Medicare. Medicare rules for coverage of this testing have not been met.Therefore, we decided that the Plan does not have to pay fora comprehensive panel of influenza diagnostic testingprovided to the enrollee on July 27, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forthe tissue transfer provided on March 19, 2020.You asked the Plan to pay forthe services provided. You say that the denial was processed incorrectly.The Plan denied your request. The Plan says the billed code is not supported in the documentation.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 14021 is adjacent tissue transfer or rearrangement, scalp, arms and/or legs; defect 10.1 squarecentimeters (cm)to 30.0 squarecm. We find that CPT code 14021 is not supported in the medical record. The records indicate that the area elipsed was 9 cmby 5 cm wide. Based on this information, we decided that Medicare rules for coverage have not been met.Therefore, we decided that the Plan does not have to pay forthe tissue transfer provided on March 19, 2020
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia.
You asked the Plan to pre-approve Prolia. You say that you would like the plan to reconsider their denial. The
Plan denied your request. The Plan says the requested drug is not medically necessary.
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 Prolia. Our reviewer says that the
documentation does not support that the requested drug is medically reasonable or necessary. Our physician
reviewer found the enrollee has age-related osteoporosis without current pathological fracture. The
documentation does not support that the enrollee has tried and failed zoledronic acid. The documentation does
not support that zoledronic acid would be less effective and/or likely have adverse effects for the enrollee.
Therefore, the enrollee does not meet criteria for the requested drug.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to
pre-approve Prolia.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve external female catheters.
You asked the Plan to pre-approve external female catheters. You say that you are requesting the catheters to be able to control your nighttime incontinence. The Plan denied your request. The Plan says Medicare does not cover incontinence supplies because they are disposable, non-reusable hygiene items and fall outside the scope of coverage.
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve external female catheters.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the continuation of home health services.
You asked the Plan to pre-approve the continuation of home health services. You say that the requested
continuation of home health services is medically necessary. The Plan denied your request. The Plan says the
requested continuation of home health services is not medically necessary.
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically
necessary for the enrollee to receive skilled nursing or 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 the continuation of home health
services. Our reviewer says that the requested continuation of home health services is not medically necessary.
Our physician reviewer found in this case, the documentation doesn't support that the member requires skilled
nursing services or skilled rehab services to provide treatment that is medically necessary. The member does
not require skilled nursing or rehab services to effectively provide treatment, care, and/or services in order to
improve the member's condition, perform a maintenance program to maintain the member's condition and/or
prevent deterioration. The member has been medically stable without any recent exacerbations of chronic
medical problems or hospitalizations. She has been discharged from all skilled nursing services from
11/5/2020. The documentation supports that she is at her baseline level of function and general health.
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 continuation of home health services have not been met. Therefore, we
decided that the Plan does not have to pre-approve the continuation of home health services.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve thoracic laminectomy and fusion with spinal stimulator placement
(20930, 63685, 95972, 63655, 63685).
You asked the Plan to pre-approve the laminectomy and fusion. You say that you hope this letter demonstrates
the enrollee's condition warrants the proposed surgical treatment and hope for reversal of the denial of
treatment which is in the best interest of the enrollee. The Plan denied your request. The Plan says that the
medical necessity of the requested procedure has not been established. The requested procedures are not
keeping with the current standards of care and do not meet plan criteria.
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 laminectomy and fusion. Our
reviewer says that the requested items/services are considered medically reasonable and necessary in this case.
Our physician reviewer found the Medicare criteria have been fully met for spinal cord stimulator placement
which requires a laminectomy at one, and possibly two levels for placement of a second lead. Additionally, the
medical necessity of fusion would be supported should wide decompression/facet resection be required and
result in temporary intraoperative instability. Therefore, this request for spinal surgery and placement of the
spinal cord stimulator 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 the laminectomy and fusion have been met. Therefore, we decided that the Plan
has to pre-approve thoracic laminectomy and fusion with spinal stimulator placement (20930, 63685, 95972,
63655, 63685).
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.