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

We decided that the Plan does not have to pay for the shoulder elbow wrist hand orthosis (L3960).

You asked the Plan to pay for the shoulder elbow wrist hand orthosis. You say that the orthosis was medically necessary. The Plan denied your request. The Plan says there is no evidence prescribing physician saw the member.

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 pay for the shoulder elbow wrist hand orthosis. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the provided documentation does not credibly support the existence of a physician-patient relationship. The documentation does not credibly indicate that an examination of the enrollee occurred. Therefore, the medical necessity and reasonableness of the requested service has not been demonstrated and cannot be recommended.

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 shoulder elbow wrist hand orthosis have not been met. Therefore, we decided that the Plan does not have to pay for the shoulder elbow wrist hand orthosis (L3960).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that an IRF admission is medically necessary. The Plan
denied your request. The Plan says you do not meet criteria for coverage of an IRF admission.
The Plan must follow Medicare rules. The rules say that an 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 that the complexity of your nursing, medical and rehabilitation needs does not require
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for
lumbar fusion surgery. Your medical problems are stable. You do not have complex nursing or rehabilitation
needs.
You do not require treatment by multiple therapies, including either physical therapy or occupational therapy,
and an intensive rehabilitation therapy program. While the medical 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.
Additionally, 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 an acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve placental allograft services.
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says it is not generally accepted for the proposed use.
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 requested services. Our physician reviewer found that you have right knee pain due to osteoarthritis. You use Ibuprofen for pain. You have had physical therapy and had a Synvisc injection, which did not provide sustained relief. You also had prolotherapy, which did not provide sustained pain relief. The requested services are an experimental/ investigational approach. 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 requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve placental allograft services.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan does not have to pre-approve a sacroiliac joint injection for the enrollee.

You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says the medical records received did not support the medical necessity of the requested procedure.

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 injection. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the first joint injection produced only 50% pain relief and increased mobility or decreased medication use is not documented. Further, there is a disc protrusion which is not addressed. The request is deemed 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 injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a sacroiliac joint injection for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex Superion Indirect Decompression system.
You asked the Plan to pre-approve a Vertiflex Superion Indirect Decompression system. You say that the
services are necessary. The Plan denied your request. The Plan says medical necessity has not been established.
Therefore, coverage criteria have 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 a Vertiflex Superion Indirect
Decompression system. Our reviewer says that the requested items/services are not considered medically
reasonable and necessary in this case. Our physician reviewer found the Vertiflex spacer device remains
experimental for use in spinal surgery. More research is needed to show safety and efficacy. Open lumbar
laminectomy is the gold standard procedure for spinal stenosis decompression.
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 Vertiflex Superion Indirect Decompression system have not been met.
Therefore, we decided that the Plan does not have to pre-approve a Vertiflex Superion Indirect Decompression
system.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a new complete lower limb prosthesis.
You asked the Plan to pre-approve the prosthesis. You say that this is medically necessary. The Plan denied your request. The Plan says a request for new complete lower limb prosthesis with K3 foot does meet Medicare criteria as reasonable and 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 prosthesis. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the request for the new prosthesis and K3 foot are not medically necessary per the Local Coverage Determination (LCD): Lower Limb Prostheses (L33787) and per Social Security Act, Section 1862 (a)1(A) and the 42 CFR 411.15(k), as Medicare does not pay for any items or services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body. The requested items exceed your medical need as the physician progress note documentation does not support that you are a level K3 ambulator given your multiple comorbidities, needing a cane, and having a power wheelchair approved in 2020. 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 prosthesis have not been met. Therefore, we decided that the Plan does not have to pre-approve a new complete lower limb prosthesis.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the COVID-19 testing rendered on August 3, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a physician who has furnished a consultation or treats an enrollee for a specific medical problem. The file does not contain documentation of an established relationship between the enrollee and the ordering provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this testing have not been met. Therefore, we decided that the Plan does not have to pay for the COVID-19 testing rendered on August 3, 2020.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Supartz.
You asked the Plan to pre-approve Supartz. The Plan denied your request. The Plan says the enrollee has not tried and failed Orthovisc and Monovisc.
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 Supartz. Our physician reviewer found that the enrollee has osteoarthritis of the knees. The Plan requires a trial of Orthovisc and Monovisc before they will approve the requested drug. In this case, the enrollee has not tried and failed the required drugs. There is no documentation provided indicating that the Plan's required drugs would likely be less effective, or likely have adverse effects 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 Supartz have not been met. Therefore, we decided that the Plan does not have to pre-approve Supartz.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xtampza ER 18 mg capsule.

You asked the Plan to pre-approve Xtampza ER. You say that this drug is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says this medication is not covered under the enrollee's medical benefit.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Xtampza ER 18 mg capsule.

Benefits for Xtampza ER may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the deep sedation/anesthesia services (D9222, D9223).

You asked the Plan to pre-approve the deep sedation/anesthesia services. You say that these services are medically necessary. The Plan denied your request. The Plan says these services are not covered under your supplemental benefit.

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 the deep sedation/anesthesia services (D9222, D9223).
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 needs a lower level of care to be safe. The Plan denied your request. The Plan says the services are not medically necessary.

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 medically necessary. Our physician reviewer found the enrollee was admitted to the hospital for confusion and mental status changes. His medical problems are stable and he has no complex nursing or rehabilitation needs. He does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 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 the 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: Unfavorable

We decided that the Plan does not have to pre-approve a computerized tomography (CT) scan.
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 CT scan is 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 generalized mild abdominal pain. No physical examination findings noted.
There was insufficient objective supportive information provided such as significant physical findings or other
image findings requiring follow-up CT imaging. Therefore, the enrollee does not meet criteria for the requested
CT scan.
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.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA).

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that items and services that RFA is covered when specific criteria are met.

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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has chronic low back pain. There is a new onset of radicular pain after feeling a snap in her back. Previous facet RFA provided less than three months of pain relief and there is no documentation of improved functioning. The repeat RFA is therefore not reasonable or medically necessary.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation (RFA).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve palliative care visits.
You asked the Plan to pre-approve palliative care visits. You say that you had been receiving these medically necessary services and it has been emotional for you since coverage was taken away. You say that you have 15 diagnoses that are mostly pain related. You say that these conditions are getting worse and that you need specialized care. The Plan denied your request. The Plan says palliative care services are not medically necessary because there are no skilled qualifiers or skilled services that need to be rendered.
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 palliative care visits. Our reviewer says that palliative care visits are not considered medically reasonable and necessary in this case. Our physician reviewer found that you are at your baseline status and that ongoing care is custodial in nature, as there is no expectation of improvement or progress. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of palliative care visits have not been met. Therefore, we decided that the Plan does not have to pre-approve palliative care visits.
Appeal type: Imaging
Decision: Partially Favorable

We decided that the Plan has to pre-approve the CT scans. We decided that the Plan does not have to pre-approve the CT scan of the thorax.

You asked the Plan to pre-approve the CT scans. You say that the information that has been submitted warrants the need for the requested CT scans. The Plan says that the CT of the abdomen and pelvis is not appropriate because the requested region would not show the doctor all of the details needed in order to treat the enrollee. The Plan says that the CT of the thorax does not meet the guidelines for coverage because they have not received the results of a chest x-rays or an exam done by a doctor showing the reason this study is needed.

We decided that the Plan has to pre-approve the CT scan of the abdomen and pelvis.

The Plan follows 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 scans. Our reviewer says that a CT scan of the abdomen and pelvis is medically necessary. Our physician reviewer found the enrollee reported weight loss, loss of appetite, leukocytosis, thrombocytosis, and left kidney lesion seen on prior ultrasound. Renal magnetic resonance imaging (MRI) was non-diagnostic due to motion artifact, and a renal CT was arranged. A renal CT scan is medically reasonable and necessary as the MRI had too much artifact to be useful at ruling out a mass.

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 scans have been met. Therefore, we decided that the Plan has to pre-approve the CT scan of the abdomen and pelvis.

We also decided that the Plan does not have to pre-approve the CT scan of the thorax.

The Plan follows 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 of the thorax. Our reviewer says that a CT scan of the thorax is not medically necessary. Our physician reviewer found a chest radiograph showed no pneumonia or other acute abnormality. A CT of the thorax is not supported by the documentation.

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 of the thorax have not been met. Therefore, we decided that the Plan does not have to pre-approve the CT scan of the thorax.

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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Durolane 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 the plan's preferred supplements do not require prior authorization.
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 the drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found there is no evidence of a trial and failure of the required drugs - Orthovisc and Monovisc. There is no evidence to support that the required drugs would likely be less effective and/or likely have adverse effects 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 Durolane for the enrollee.