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

We decided that the Plan does not have to pay for physical therapy services provided to the enrollee on September 23, 2019.You asked the Plan to pay for the services. You say that this should be paid for.The Plan denied your request. The Plan says Current Procedural Terminology (CPT) code 97110, 97112, and 97530 remain not supported.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 the denied codes is:CPT 97110:therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility CPT 97112:therapeutic procedure, 1 or more areas, each 15 minutes; neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities CPT 97530:therapeutic activities, direct patient contact, each 15 minutes 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 pay for the services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our physician reviewer found the documentation does not support that therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility was performed on 9/23/19. There was no detailed record of the amount of time spent per activity. 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 pay for physical therapy services provided to the enrollee on September 23, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Piqray (J8999) for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says this is indicated in combination with fulvestrant for the treatment of breast cancer.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found the enrollee has a diagnosis of metastatic spindle cell cancer of the right breast positive for PIC3CA mutation. The request is for Piqray as monotherapy. Piqray in combination with fulvestrant is supported by the Medicare Compendia for use in this clinical situation but tt's use as monotherapy is not supported. The documentation does not support that the Piqray is medically reasonable and necessary for the enrollee. The documentation does not support that the Piqray is safe and effective for the enrollee. 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 drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Piqray (J8999) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the nerve treatment on tooth #13 (D3320) and the high gold content crown on tooth #13 (D2790).
You asked the Plan to pre-approve the nerve treatment on tooth #13 (D3320) and the high gold content crown on tooth #13 (D2790). You say that the services are medically necessary and you cannot eat. The Plan denied your request. The Plan says the services are not medically necessary
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 nerve treatment on tooth #13 (D3320) and the high gold content crown on tooth #13 (D2790) 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 nerve treatment on tooth #13 (D3320) and the high gold content crown on tooth #13 (D2790). Our reviewer says that the services are not medically necessary. Our physician reviewer found the provided x-rays do not show tooth #13. Therefore, given the lack of clinical information as to the status of #13, our physician reviewer says there can be no finding of medical necessity for the requested endodontic treatment or crown for#13.
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 nerve treatment on tooth #13 (D3320) and the high gold content crown on tooth #13 (D2790) have not been met. Therefore, we decided that the Plan does not have to pre-approve a nerve treatment on tooth #13 (D3320) and a high gold content crown on tooth #13 (D2790).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean oral device to be provided by an out of network (OON) provider.You asked the Plan to pre-approvethe OON services. You say that the enrollee is not able to travel.The Plan denied your request. The Plan says there are participating providers available in network that can provide the requested service.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 at issue in this appeal. We found no exception that would require the Plan to pre-approve these services.Therefore, we decided that the Plan does not have to pre-approvean oral device 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-approve a raised toilet seat.You asked the Plan to pre-approve the seat. You say that this is medically necessary.The Plan denied your request. The Plan says there is no documentation of a fall, hip fracture, or knee/hip replacement in the last year.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. The supplemental plan rules are also not met in this case, as there is no history of falls, hip/knee replacement, or fractures.Therefore, we decided that the Plan does not have to pre-approve a raised toilet seat.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional logisticare mileage.
You asked the Plan to pre-approve additional logisticare mileage. You say that the additional mileage is needed. The Plan denied your request. The Plan says the requested additional mileage exceeds the benefit limit. Therefore, coverage criteria has not been met.
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 60 one-way transportation trips per calendar year when each one-way trip does not exceed 50 miles. 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 logisticare mileage.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of botulinum toxin A (Botox).You asked the Plan to pre-approve Botox. You say that the enrollee is losing weight and is unable to eat, therefore this treatment is necessary.The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because studies have no proven that this drug is helpful for treatment of the enrollee's condition.The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Botox. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested use of Botox. Our physician reviewer found though trials evaluating the effect of intrapyloric botulinum toxin injection on gastroparesis have been reported, there is no agreement on whether botulinum toxin can effectively relieve the symptoms and improve the results of gastric emptying studies in enrollees with gastroparesis. It is unclear if proton pump therapy is in use. The submitted records do not provide objective documentation of gastroparesis by gastric emptying scan. Results of a domperidone trial were not provided.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Botox have not been met.Therefore, we decided that the Plan does not have to pre-approve use of botulinum toxin A (Botox).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient mental health care from July 6, 2020 on.
You asked the Plan to pre-approve inpatient mental health. You say that this is medically necessary. The Plan denied your request. The Plan says you could be treated at a lower level of care.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 inpatient mental health. Our reviewer says that the requested inpatient care is not medically necessary. Our physician reviewer found based on the records provided, it is not expected you would improve in a reasonable period of time beyond the dates in question as you are not showing any dangerousness to yourself or others, auditory or visual hallucinations, or aggressive behaviors. You are still oriented to person place and time. It did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the dates in question as you did not have any suicidal or homicidal thoughts, auditory or visual hallucinations or abnormal behaviors. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient mental health have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient mental health care from July 6, 2020 on.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide a tilt option to be added to your power wheelchair.You asked the Plan to provide a tilt option. You say that you need a tilt option for comfort and pain relief.The Plan denied your request. The Plan says a tilt option is not necessary.The Plan must follow Medicare rules. Medicare rules say that PACE plans must cover all services determined necessary by the IDT to improve and maintain the enrollee's overall health status.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 provide a tilt option. Our reviewer says that a tilt option is not reasonable and medically necessary. Our physician reviewer found the documentation does not support that the requested services are services necessary and reasonable to meet the enrollee's needs and to improve and maintain the enrollee's overall health status. The documentation does not reveal that the enrollee has recently attempted traditional methods recommended by the therapist such as PT, regular pain management visits, and positioning devices. Furthermore, the enrollee has no history of skin breakdown but there is concern that the tilt feature will lead to skin breakdown as well as make the enrollee more sedentary than currently is. The  requested services are not cosmetic or experimental.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 tilt option have not been met.Therefore, we decided that the Plan does not have to provide a tilt option to be added to your power wheelchair.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says the services can be safely received in other settings.
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 enrollee was medically stable, with no evidence of need for supervision by a PMR physician. There is no need for acute rehab nursing care. Functionally, given his low endurance, he will not be able to take part in three hours a day of therapy. The enrollee does not require the IRF level of therapy. The enrollee may benefit from further PT and OT, but does not require an intensive therapy program. The admission is not medically necessary based on the enrollee's current endurance level and medical stability. 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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.You asked the Plan to pre-approveIRF care. You say that this is medically necessary.The Plan denied your request. The Plan says the services can be safely received in other settings, for example: a skilled nursing facility, home with home health and home physical therapy, or home with outpatient therapy.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at a lower level of care (ex. SNF/SAR).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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Magnetic Resonance Imaging (MRI) of the breast
(77049).
You asked the Plan to pre-approve the MRI. You say that the MRI 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 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 reviewer says that the
MRI is not medically necessary. Our physician reviewer found breast density alone is not an indication for
regular MRI's. The current evidence does not suggest improved outcomes for women whose only risk factor is
breast density. Annual mammogram or ultrasound is most appropriate for this enrollee based on the clinical
information provided, which did not include any evidence of a genetic mutation or family history which would
place her in a high risk category.
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 Magnetic Resonance Imaging (MRI) of the breast (77049).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a fluoroscopy (76000).
You asked the Plan to pre-approve the fluoroscopy. You say that the fluoroscopy is medically necessary. The
Plan denied your request. The Plan says the fluoroscopy was already approved as part of the procedure, a
second, separate fluoroscopy 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 fluoroscopy. Our reviewer says that
the requested imaging is not medically necessary. Our physician reviewer found the prescribing physician
requested fluoroscopy to help insert a neurostimulating device (Interstim). The Interstim implantation
procedure was approved, including imaging guidance. Fluoroscopy was not approved as it was a separate
imaging procedure when imaging was already included in the approved request for the procedure.
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 fluoroscopy have not been met. Therefore, we decided that the Plan does not
have to pre-approve a fluoroscopy (76000).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a non-therapeutic continuous glucose monitor (CGM).
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the
requested device is not considered a therapeutic device.
The Plan must follow Medicare rules. Medicare rules say that CGMs that are approved by the FDA for use as
adjunctive devices to complement information obtained from blood glucose monitors in making diabetes
treatment decisions are referred to as non-therapeutic CGMs.
We looked at the file and Medicare rules. The requested device is considered non-therapeutic. 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 pre-approve a non-therapeutic continuous glucose monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a semi-electric hospital bed (E0260).
You asked the Plan to pre-approve a semi-electric hospital bed. You say that you need this because you keep
falling out of bed and cannot sit up. The Plan denied your request. The Plan says this is not medically
necessary.
The Plan follows Medicare rules. Medicare rules say that a semi-electric hospital bed is covered if the
beneficiary meets one of the criteria for a fixed height bed and requires frequent changes in body position
and/or has an immediate need for a change in body position.
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 semi-electric hospital bed. Our
reviewer says that the criteria for coverage of a semi-electric hospital bed has not been met. Our physician
reviewer found the medical records provided do not show that you require frequent changes in body position or
have an immediate need for a change in body position. In addition, the records do not clearly show that you
meet any of the criteria for a fixed height bed.
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 semi-electric hospital bed have not been met. Therefore, we decided that the
Plan does not have to pre-approve a semi-electric hospital bed (E0260).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genicular nerve destruction for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your
request. The Plan says this procedure is still being studied in clinical trials for efficacy in the treatment of knee
pain due to osteoarthritis, or in the setting of replacing or significantly deferring total knee arthroplasty.
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 services are not considered medically reasonable and necessary in this case. Our physician reviewer
found this is considered an experimental/investigational procedure that is the subject of ongoing clinical trials.
Therefore, the request is 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 services have not been met. Therefore, we decided that the Plan does not
have to pre-approve genicular nerve destruction for the enrollee.