Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Superion interspinous spacer procedure.

You asked the Plan to pre-approve the Superioninterspinous spacer procedure. You say that the insertion of a lumbar interspinous spacer would provide significant clinical and quality of life benefits for the enrollee. You say that the requested treatment is medically necessary and appropriate for the stage of the enrollee's disease progression.The Plan denied your request. The Plan says the requested service is considered experimental and investigational. The Plan says that it is not identified as widely used and generally accepted for the proposed use as reported in nationally recognized peer-reviewed medical literature.

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 Superion interspinous spacer procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the requested device is considered experimental. Our physician reviewer found that more research is needed to show the safety and efficacy of the device.

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 Superion interspinous spacer procedure have not been met.Therefore, we decided that the Plan does not have to pre-approvethe Superion interspinous spacer procedure
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH is not medically necessary.
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 admission to a LTACH is not medically necessary. Our physician reviewer found based on the documentation provided, the enrollee is currently undergoing treatment at an acute care hospital (ACH) for shortness of breath and pneumonia in the setting of idiopathic pulmonary fibrosis. The enrollee is not intubated/ventilated. 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. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care needs.
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.
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 chest pain and had coronary artery bypass surgery. 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.
You asked the Plan to pay for the ambulance services. You say that you fell and your position needed action as soon as possible. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on July 3, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approveextracapsular cataract removal with insertion of intraocular lens prosthesis (1 stage procedure), manual or mechanical technique (e.g., irrigation and aspiration or phacoemulsification); without endoscopic cyclophotocoagulation (CPT Code 66984) to be performed by an out-of-network provider.You asked the Plan to pre-approvethe services. You say that your cataracts are getting worse and is riskier every day the surgery is delayed.The Plan denied your request. The Plan says the request will be approved if a contracted provider is not able or available to give the needed service. The Plan states or, if the service that is being requested isan emergency. The Plan states your records show that your health problem is stable and that the Plan previously referred you to see a contracted eye doctor. The Plan states they previously approved authorizations to a contacted eye specialist that remain valid for continued care with him.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 thisappeal. 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-approveextracapsular cataract removal with insertion of intraocular lens prosthesis (1 stage procedure), manual or mechanical technique (e.g., irrigation and aspiration or phacoemulsification); without endoscopic cyclophotocoagulation(CPT Code 66984) to be performed by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy (99601 and S9501) provided on January 9, 2020 through January 27, 2020.
You asked the Plan to pay for home infusion therapy. You say that the service was medically necessary. The Plan denied your request. The Plan says the Plan says home infusion of antibiotics is not a covered benefit under Medicare or the Plan contract.
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 S9501 is home infusion therapy, antibiotic, antiviral, or antifungal therapy; once every 12 hours; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem. We find that CPT code S9501 is not supported in the medical record. Specifically, home infusion therapy is not a covered benefit. Based on this information, we decided that Medicare rules for coverage of home infusion therapy have not been met. Therefore, we decided that the Plan does not have to pay for home infusion therapy (99601 and S9501) provided on January 9, 2020 through January 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable ventilator for the enrollee.
You asked the Plan to pre-approve a portable ventilator. You say that this is medically necessary. The Plan
denied your request. The Plan says that ventilators used to provide CPAP or bi-level CPAP therapy for
conditions described in this RAD policy will be denied as not reasonable and necessary.
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory
failure due to COPD.
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 portable ventilator. Our reviewer says
that a portable ventilator is not medically reasonable and necessary for the enrollee in this case. The patient
does not have respiratory failure related to her COPD and was supported effectively with the BiPAP at night.
Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for a portable
ventilator.
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 portable ventilator have not been met. Therefore, we decided that the Plan
does not have to pre-approve a portable ventilator for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Prolaris prostate testing provided on December 27, 2019.
You asked the Plan to pay for the testing services. You say that the enrollee meets coverage criteria. The Plan
denied your request. The Plan says more research is needed to prove the testing leads to improved net health
outcomes.
The Plan must follow Medicare rules. Medicare rules say that Prolaris testing is only covered under certain
medical indications.
We looked at the file and Medicare rules. In this case, there is insufficient medical records provided to show
that all of the clinical conditions have been met. 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 for the Prolaris prostate
testing provided on December 27, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Intracept procedure.
You asked the Plan to pre-approve the Intracept procedure. The Plan denied your request. The Plan says this
procedure is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the Intracept procedure. Our reviewer
says that the requested services are not considered medically reasonable and necessary in this case. Our
physician reviewer found that there is no discussion or physical therapy notes provided to support that
maximized physical therapy treatment has failed to provide relief. There is a lack of large volume, long-term
peer-reviewed outcome studies to support the use of these procedures for this enrollee. A current clinical trial is
underway with no results posted. Therefore, the requested Intracept procedure is not medically reasonable and
necessary for treatment of this enrollee's medical condition.
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 Intracept procedure have not been met. Therefore, we decided that the Plan
does not have to pre-approve the Intracept procedure.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approveperiprosthetic capsulectomy, breast, left breast (19371) immediate insertion of breast prosthesis following mastopexy, mastectomy or in reconstruction, left breast (19340).You asked the Plan to pre-approveperiprosthetic capsulectomy and immediate insertion of breast prosthesis. You say that the left breast currently is not ruptured, however since it is more than 10 years old, the likelihood of the left implant rupturing in the near future is there.The Plan denied your request. The Plan says that the request is not medically necessary because the records do not show that there is any problems with the left breast implant.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 periprosthetic capsulectomy and immediate insertion of breast prosthesis. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is a 74-year old female with a remote history of medically necessary mastectomy and reconstruction with breast implants.  Her most recent breast implant surgery was over 20 years ago. She is noted to have evidence of a ruptured right breast saline implant. Standard breast reconstruction would be to intervene surgically on both sides to ensure that symmetry can be adequately obtained and due to the age of the implants. Therefore, bilateral implant exchange and capsulectomy satisfies Medicare medically necessary criteria.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of periprosthetic capsulectomy and immediate insertion of breast prosthesis have been met.Therefore, we decided that the Plan has to pre-approveperiprosthetic capsulectomy, breast, left breast (19371) immediate insertion of breast prosthesis following mastopexy, mastectomy or in reconstruction, left breast (19340).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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve endodontic therapy, molar tooth (excluding final restoration) (D3330).
You asked the Plan to pre-approve the dental services. You say that you are in pain and need a root canal. The Plan denied your request. The Plan says the service is not a covered benefit under the 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. This service is not listed in your handbook as a covered benefit; therefore, it is not covered. Therefore, we decided that the Plan does not have to pre-approve endodontic therapy, molar tooth (excluding final restoration) (D3330).
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 weakness and confusion. 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: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve MRI, any joint of upper extremity; without contrast material(s) (CPT Code 73221).
You asked the Plan to pre-approve the MRI. You say that the MRI is necessary. The Plan denied your request. The Plan says that the MRI is not necessary.
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 the documentation is sufficient to justify MRI of shoulder(s). There is documented concern for rotator cuff injury. MRI is best means for evaluation of injury and is medically necessary and indicated for proper management. 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 been met. Therefore, we decided that the Plan has to pre-approve MRI, any joint of upper extremity; without contrast material(s) (CPT Code 73221).
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvedental implants (D6010), prefabricated abutments (D6056), and an implant/abutment supported fixed denture (D6115).You asked the Plan to pre-approvedental implants, prefabricated abutments, and implant/abutment supported fixed dentures. You say that the implants, abutments, and implant/abutment supported dentures are necessary in order for the enrollee to obtain chewing function and proper digestion.The Plan denied your request. The Plan says the services being requested are not covered under the enrollee's benefit package.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-approvedental implants (D6010), prefabricated abutments (D6056), and an implant/abutment supported fixed denture (D6115).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a surgical revision (22849, 222850, 22852, 22210).
You asked the Plan to pre-approve the surgical revision. You say that the surgical procedure is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
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 surgical revision. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the medical records do not justify the need for revision spinal surgery. There is not enough documentation of physical disability or impairment. 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 surgical revision have not been met. Therefore, we decided that the Plan does not have to pre-approve a surgical revision (22849, 222850, 22852, 22210).