Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Orthovisc.
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 that the services are not medically necessary.
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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has pain related to right shoulder osteoarthritis confirmed on imaging studies. He has failed conservative treatment with home exercises. The Medicare-approved compendia include a citation reporting non-FDA approved, off-label benefits of Orthovisc for shoulder arthropathy. The Orthovisc is reasonable and medically necessary and safe and effective for the enrollee at this time. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have been met. Therefore, we decided that the Plan has to pre-approve Orthovisc.
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ExomeNext A Proband + Mito testing (81415, 81460).
You asked the Plan to pre-approve ExomeNext A Proband + Mito testing. You say that this is medically necessary. The Plan denied your request. The Plan says this is not covered.
The Plan must follow Medicare rules. Medicare rules say that genetic testing procedures submitted under the CPT codes 81415 and 81460 are unlikely to impact therapeutic decision-making in the clinical management of the patient and will be denied automatically as not medically necessary. We looked at the file and Medicare rules. The requests tests are not considered medically neceBased on this information, we decided that Medicare rules for coverage of ExomeNext A Proband + Mito testing have not been met. Therefore, we decided that the Plan does not have to pre-approve ExomeNext A Proband + Mito testing (81415, 81460).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested admission is 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 considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee required moderate assistance to scoot and sit up. The enrollee's pain was better controlled. The documentation does not support that the enrollee requires an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not support that the enrollee requires an intensive rehabilitation therapy program. The enrollee's care needs can be met at a lower level of care. 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient services provided from March 6, 2020, through March 9, 2020 with the reported principal diagnosis A41.9, sepsis, unspecified organism.
You asked the Plan to pay for the inpatient services provided from March 6, 2020, through March 9, 2020 with the reported principal diagnosis A41.9, sepsis, unspecified organism. The Plan denied your request. The Plan says the medical record received do not support the condition treated as consistent with a systemic infectious process.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes. In this case, you billed the inpatient services provided with reported principal diagnosis A41.9, sepsis, unspecified organism. 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 inpatient services provided from March 6, 2020, through March 9, 2020 with the reported principal diagnosis A41.9, sepsis, unspecified organism. Our reviewer says that the documentation does not support that the inpatient care is
payable as billed. Our physician reviewer found the review indicates that the enrollee was evaluated in the ER and admitted with a diagnosis of pneumonia. On presentation she had fever, tachycardia and tachypnea. Her WBC was elevated to 16.5. The CXR demonstrated bilateral opacities. She was treated with supplemental oxygen, fluids and IV antibiotics. Her condition stabilized and improved; she had no evidence of physiologic instability. The review indicates that the principal diagnosis A41.9, sepsis, unspecified organism, was not supported by the medical records. The review supports DRG 193. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for inpatient services provided from March 6, 2020, through March 9, 2020 with the reported principal diagnosis A41.9, sepsis, unspecified organism.
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 this is medically necessary. The Plan denied your request. The Plan says the enrollee can be treated at a lower level of care.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the records show that the patient was admitted for pneumonia, renal failure and delirium. Her medical problems are stable. There are no complex nursing or rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary services can be provided in a different level of care. 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the consultation for a Smart pill test to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the consultation for a Smart pill test. You say that you would like to appeal the denial. You say you have an appointment with an in-network provider, but it is not until the end of May. The Plan denied your request. The Plan says the provider is out-of-network.
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 the consultation for a Smart pill test 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 heavy duty, extra wide, hospital bed.
You asked the Plan to pre-approve Hospital bed, heavy duty, extra wide, with weight capacity greater than 350 pounds, but less than or equal to 600 pounds, with any type side rails, with mattress (E0303). You say that a standard bed will not fit for the enrollee. The Plan denied your request. The Plan says there is no documentation supporting criteria.
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered medically necessary when the patient: 1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 2. Requires attachments which can only be attached to a hospital bed; AND 3. Requires frequent changes in body position and/or has an immediate need for a change in body position. We looked at the file and Medicare rules. The enrollee does not weight more than 350 pounds and the record
does not show the enrollee needs positioning of the body that cannot be done in an ordinary bed. Based on this information, we decided that Medicare rules for coverage of Hospital bed, heavy duty, extra wide, with weight capacity greater than 350 pounds, but less than or equal to 600 pounds, with any type side rails, with mattress (E0303) have not been met. Therefore, we decided that the Plan does not have to pre-approve a heavy duty, extra wide, hospital bed.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a biological implant (15777).
You asked the Plan to pre-approve this service. You say that this service is medically necessary for the enrollee. The Plan denied your request. The Plan says this service 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 this service. Our reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our physician reviewer found that the requested biological implant in the setting of shoulder capsular reconstruction is not medically reasonable or necessary. This enrollee was being treated for left shoulder pain and shoulder tendinitis. She presented with shoulder pain that was of gradual and insidious onset. The left shoulder pain is constant, aching, and dull with associated limited motion and stiffness. There is difficulty with activities of daily living. The exam reveals grossly limited range of motion with pain and active motion is noted to have limited forward flexion and abduction with pain noted on all ranges of motion. However, there is very limited published, long-term, peer-reviewed literature that shows the request to be an effective and/or safe treatment for the noted pathology. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines. Therefore, the request for biological implant in the setting of shoulder capsular reconstruction is not medically reasonable or necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pre-approve a biological implant (15777).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says there is concern that this device is not as effective as surgical decompression, and may lead to higher rates of reoperation.
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 device. 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 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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a custom silicone cosmetic glove (L7499) for an upper extremity prosthesis.
You asked the Plan to pre-approve the silicone cosmetic glove. You say that the cosmetic glove protects the prosthesis and serves as a second point to carry and balance objects above his head. The Plan denied your request. The Plan says the custom silicone glove does not meet the definition of DME.
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. Therefore, we decided that the Plan does not have to pre-approve a custom silicone cosmetic glove (L7499) for an upper extremity prosthesis.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that you cannot walk without inserts. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nerve block described by current procedural terminology (CPT) code 64415 provided on July 31, 2020.
You asked the Plan to pay for CPT code 64415. You say that the medical records support the billing of CPT code 64415. The Plan denied your request. The Plan says the medical records do not support the billing of CPT code 64415.
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 64415 is NJX AA&/STRD BRACH PLEXUS Injection(s), anesthetic agent(s) and/or steroid; brachial plexus. 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 CPT code 64415. Our reviewer says that the medical records do not support the billing of CPT code 64415. Our physician reviewer found in this case; the documentation provided indicates the right femoral nerve was blocked. The elements of the coverage rule are not satisfied. The requested service 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 CPT code 64415 have not been met. Therefore, we decided that the Plan does
not have to pay for the nerve block described by current procedural terminology (CPT) code 64415 provided on July 31, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a porcelain crown (D2740) for tooth # 13.
You asked the Plan to pre-approve the dental service. You say that the crown for tooth # 13 is medically necessary. The Plan denied your request. The Plan says porcelain crown is not listed as a covered service.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a porcelain crown (D2740) for tooth # 13.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided on August 4, 2020.
You asked the Plan to pay for a lumbar-sacral orthosis. You say that the requested item is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for a lumbar-sacral orthosis have not been met because there is no evidence of an established relationship between the enrollee and the ordering physician.
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 a lumbar-sacral orthosis. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee's chief complaint was lower back pain. The available documentation in the case file does not support that the requested lumbar-sacral orthosis was medically reasonable and necessary for the enrollee in this case, according to the coverage criteria established by Medicare. An appropriate history and a physical examination of the back would reasonably be required to adequately assess whether the coverage criteria for a lumbar-sacral orthosis have been met. The documentation does not support that the lumbar-sacral orthosis was prescribed for one or more of the covered indications in this case, as there is insufficient documentation of an appropriate evaluation of the enrollee and insufficient documentation of a credible physical examination of the back.
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 lumbar-sacral orthosis have not been met. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided on August 4, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the breast reduction surgery to be provided by an out of
network (OON) provider.
You asked the Plan to pre-approve the breast reduction surgery. You say that you would like to appeal the
denial. The Plan denied your request. The Plan says the provider is out-of-network.
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
the breast reduction surgery to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a out-of-network referral for behavioral health.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says it is not medically necessary to receive care out-of-network.
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 out-of-network referral for behavioral health.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a core buildup, including any pins when required (D2950).
You asked the Plan to pre-approve the core buildup. You say that this service is necessary. The Plan denied your request. The Plan says this service is not a covered 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 a core buildup, including any pins when required (D2950).