Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation.

You asked the Plan to pre-approve radiofrequency ablation. You say that the requested radiofrequency ablation is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested radiofrequency ablation.

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 radiofrequency ablation. Our reviewer says that the enrollee does not meet criteria for the requested radiofrequency ablation. Our physician reviewer found the enrollee has chronic low back pain. He has the diagnosis of lumbar facet syndrome but also has spinal stenosis and scoliosis. He also had surgery at the level of prior Radiofrequency Ablation of his lumbar medial branch nerves. The enrollee has alternative pain generators and therefore, does not meet the criteria of the LCD. 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 radiofrequency ablation have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an auricular peripheral nerve stimulator.

You asked the Plan to pre-approve the stimulator. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered benefit.

The Plan must follow Medicare rules. Medicare rules say that auricular stimulation is not covered. 

The file shows that the requested device is considered an auricular stimulation device. Based on this information, we decided that Medicare rules for coverage of the stimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve an auricular peripheral nerve stimulator.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Azacitidine.

You asked the Plan to pre-approve Azacitidine. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the enrollee is enrolled in a clinical trial.

The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in Original Medicare and the plan cost-sharing for the same services. 

In this case, you asked the Plan to pre-approve Azacitidine as part of a clinical trial. The Plan does not cover routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have to pre-approve Azacitidine.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve progressive lenses (V2781) for eyewear.

You asked the Plan to pre-approve progressive lenses. You say that you know these lenses are not covered but they are medically necessary for you. The Plan denied your request. The Plan says progressive lenses and other modifications are not covered by Medicare or by the Plan's supplemental vision benefit.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when they do not include modifications or substitutes. 

We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for eyewear coverage have not been met. Therefore, we decided that the Plan does not have to pre-approve progressive lenses (V2781) for eyewear.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips.

You asked the Plan to pre-approve the additional trips. You say that this is medically necessary. The Plan denied your request. The Plan says the benefit limit has been exceeded.

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 24 one-way trips per year. 

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 routine transportation trips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the wig purchased from an out-of-network provider.

You asked the Plan to reimburse you for the wig. You say that the wig was under $500 so it did not need
approval. The Plan denied your request. The Plan says you did not request prior authorization.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that prior authorization was needed.

The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the
item at issue. We found no exception that would require the Plan to reimburse you for this item. Therefore, we
decided that the Plan does not have to reimburse you for the wig purchased from an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services.

You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the Plan
requires utilization of network providers when possible and available and requires authorization for certain
services. No medical necessity for an out-of-network provider such as an urgent or an emergent situation that
has been documented.

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 pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the
physician's services. We found no exception that would require the Plan to pay for these services. Therefore,
we decided that the Plan does not have to pay for physician's services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation inpatient mental health care provided to the enrollee.

You asked the Plan to pre-approve inpatient mental health care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.

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 care. Our physician reviewer found the health plan's denial of continued inpatient psychiatric services appears appropriate. You do not require inpatient mental health treatment beyond the dates in question as noted above as you were not a danger to yourself or others and did not have any delusions, auditory or visual hallucinations. It did not appear that active treatment was taking place beyond the date in question. It did not appear that the services for the dates in question were reasonably expected or medically necessary to improve your condition or for the purpose of diagnosis. Our physician reviewer was unable to find an individualized treatment plan; however, the entire record is not present. It appears that the services were supervised and evaluated by a physician. Based upon review the records provided, you do not meet the criteria for treatment in an acute inpatient mental health treatment and could have been treated in a lesser restrictive setting as he was not showing any suicidal or homicidal ideation, auditory or visual hallucinations, delusions and was not showing any behaviors or aggression being cooperative and compliant while not showing any acute threats to safety while he awaited placement.

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 care have not been met. Therefore, we decided that the Plan does not have to pre-approve continuation inpatient mental health care provided to the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis (L1833) and suspension sleeve (L2397).

You asked the Plan to pay for the orthosis. You say that you trust that the verification provided will be deemed
sufficient to allow the plan to verify the claims at issue and to remit payment for the pending claims as soon as
possible. The Plan denied your request. The Plan says this enrollee did not receive video or telephonic visit by
the ordering physician in order to warrant the codes. There were no claims on file with the ordering physician
listed in the enrollee's claims history.

The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services,
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for
telehealth services only if they are presented from an authorized originating site located in either a county
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located
in a rural census tract.

A review of the file does not show that the telehealth service was provided in an authorized originating site.
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are
likewise noncovered. Therefore, we decided that the Plan does not have to pay for the knee orthosis (L1833)
and suspension sleeve (L2397).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services.

You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the services were billed incorrectly.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.

We find that the laboratory services are not supported in the medical record. Specifically, these services should
be billed with code 81479. In addition, the appropriate DEX Z code identifier should be entered adjacent to the
code in the comment/narrative field. Based on this information, we decided that Medicare rules for coverage of
the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the
laboratory services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of a Superion interspinous stabilization device (22869, 22870).

You asked the Plan to pre-approve this service. You say that this service is medically necessary. 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 spacer 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 this service have not been met. Therefore, we decided that the Plan does not have to pre-approve the insertion of a Superion interspinous stabilization device (22869, 22870).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vertiflex Superion Interspinous device.

You asked the Plan to pre-approve Vertiflex Superion Interspinous device. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.

The Plan 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 Vertiflex Superion Interspinous device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has symptomatic lumbar spinal stenosis. The Vertiflex Device is experimental. More research is needed to show safety and efficacy of the device. Therefore, the enrollee does not meet criteria for the requested services. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Vertiflex Superion Interspinous device have not been met. Therefore, we decided that the Plan does not have to pre-approve Vertiflex Superion Interspinous device.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.

You asked the Plan to pre-approve SNF care. You say that the requested SNF care is necessary for the enrollee. The Plan denied your request. The Plan says rules for SNF care have not been met.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee is a patient with spinal cord compression, status post decompression surgery, dementia, diabetes, and chronic kidney disease, currently in an inpatient rehabilitation facility. There are no identifiable skilled nursing service needs but there are identifiable skilled therapy service needs. However, the enrollee does not require skilled nursing or therapy services on a daily basis. As a practical matter, the enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Intracept System (CPT code 22899), for the enrollee.

You asked the Plan to pre-approve the service. You say that this service is medically necessary. The Plan denied your request. The Plan says medical studies have not proven that the service(s) or procedure(s) is helpful for treatment of the enrollee's health problem.

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 service. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Intracept procedure remains experimental for the treatment of back pain. More research is needed to show safety and efficacy of 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 service have not been met. Therefore, we decided that the Plan does not have to pre-approve Intracept System (CPT code 22899), for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the advanced knee and feet, K3 components (L5828, L5845, L5848, L5856, L5986 x2, L5987 x2).

You asked the Plan to pre-approve the K3 components. You say that a non-computerized knee will not provide the same level of stability and forward progression the enrollee needs as a bilateral amputee. The MPK is essential in his ability to perform activities of daily living and resume work. The Plan denied your request. The Plan says the requested K3 components and are not reasonable and necessary for the approved prosthesis.

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 K3 components. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the notes indicate that the enrollee has not used prostheses for several years and is also expected to require use of a cane, which is inconsistent with K3 functional level. There is no clinical documentation in the medical records provided to support functional level designated by the prosthetist. The signed physician order states that the enrollee is K3 ambulator. The prosthetist is the vendor and therefore has financial interest in the outcome of the claim. The requested K3 components exceed the enrollee's 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 K3 components have not been met. Therefore, we decided that the Plan does not have to pre-approve the advanced knee and feet, K3 components (L5828, L5845, L5848, L5856, L5986 x2, L5987 x2).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded G0482.

You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.

We find that CPT code G0482 is not supported in the medical record. Specifically, the place of service on the CMS-1500 form line 24B must reflect the location of the patient when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, place of service 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting place of service 11. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing coded G0482.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a total electric hospital bed.

You asked the Plan to pre-approve a total electric hospital bed. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested item is not a covered benefit.

The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered. 

While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital bed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve power wheelchair accessory, expandable controller, including all related electronics and mounting hardware, upgrade provided at initial issue (CPT code E2377), harness for upgrade to expandable controller, including all fasteners, connectors and mounting hardware, each (E2313), and electronic connection between wheelchair controller and two or more power seating system motors, including all related electronics, indicator feature, mechanical function selection switch, and fixed mounting hardware (E2311), for the enrollee.

You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your request. The Plan says the Medicare rules have not been met.

The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the DME have not been met. The expandable controller, harness, and electronic connector to 2 power options is not reasonable. Medicare never covers a power seat elevator for any reason. An attendant control is not covered if an enrollee can control the wheelchair by themselves. The enrollee is getting an enrollee-operated drive control. Thus, the attendant control cannot be covered. Therefore, we decided that the Plan does not have to pre-approve power wheelchair accessory, expandable controller, including all related electronics and mounting hardware, upgrade provided at initial issue (CPT code E2377), harness for upgrade to expandable controller, including all fasteners, connectors and mounting hardware, each (E2313), and electronic connection between wheelchair controller and two or more power seating system motors, including all related electronics, indicator feature, mechanical function selection switch, and fixed mounting hardware (E2311), for the enrollee.