Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF 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 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 based on review of the available records, the enrollee does not meet Centers for
Medicare & Medicaid Services (CMS) criteria for an IRF admission. The enrollee is medically stable with no
evidence of need for supervision by acute rehab physical medicine and rehabilitation (PMR) physician. The
enrollee may benefit from further physical therapy (PT) but does not require an intensive therapy program 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 IRF admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda.

You asked the Plan to pre-approve Keytruda. You say that this drug is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage have not been met.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. 

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 Keytruda. Our reviewer says that the request is not medically reasonable and necessary. Our physician reviewer found the enrollee is a 73-year-old diagnosed with Ovarian cancer. In this case, the requested drug is not FDA-approved for the enrollee's diagnosis. In addition, the use of Keytruda is not supported by one of the major drug compendia or by clinical research that appears in a Medicare-approved medical journal. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have to pre-approve Keytruda.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex placement procedure for the enrollee.

You asked the Plan to pre-approve these services. You say that this treatment is considered safe and effective.
The Plan denied your request. The Plan says that this is not felt to be a safe and effective treatment for this
patient.

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 these services. Our reviewer says that
the requested services are not considered medically reasonable and necessary in this case. The vertiflex device
is experimental. More research is needed to show safety and efficacy of the device. Our physician reviewer
found that the enrollee's condition does not meet Medicare criteria for SNF 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 these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve the Vertiflex placement procedure for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a knee orthosis (L1833).
You asked the Plan to pre-approve a knee orthosis. You say that this request is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage have not been met.
The Plan follows Medicare rules. Medicare rules say that the requested knee orthosis is subject to the criteria listed 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 a knee orthosis. Our reviewer says that the request is not medically necessary. Our physician reviewer found the enrollee is a 65-year-old female with knee pain due to osteoarthritis. Based on the medical records provided, there is no documentation that the enrollee meets the coverage criteria for the requested knee orthosis as listed in the Local Coverage Determination as available records do not document knee instability or joint laxity (e.g., varus/valgus instability, anterior/posterior Drawer test). 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 knee orthosis have not been met. Therefore, we decided that the Plan does not have to pre-approve a knee orthosis (L1833).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the MyoPro Motion G orthosis.

You asked the Plan to pre-approve the MyoPro Motion G orthosis. You say that this requested device is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the clinical value of the requested device in the setting of a stroke has not been demonstrated in the peer-reviewed literature.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the MyoPro Motion G orthosis. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found based on the medical records provided there is no documentation that the MyoPro Motion G orthosis in this case meets Medicare criteria for coverage as current guidelines consider robotic therapy of "uncertain utility compared with dose-matched conventional upper limb exercise therapies."

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 MyoPro Motion G orthosis have not been met. Therefore, we decided that the Plan does not have to pre-approve the MyoPro Motion G orthosis.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (S9338) provided from September 23, 2019, to October 11, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this service is not payable.
The Plan must follow Medicare rules. Medicare rules say that a status indicator of "I" under the Physician Fee Schedule indicates that the code in question is not valid for Medicare purposes. We looked at the file and Medicare rules. Code S9338 is assigned a status indicator of "I" under the Physician Fee Schedule, which means that this code is not valid for Medicare purposes. Medicare uses another code for reporting of, and payment for, these services. 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 the services (S9338) provided from September 23, 2019, to October 11, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an intermittent limb compression device.
You asked the Plan to pre-approve an intermittent limb compression device. You say that this device is medically necessary. The Plan denied your request. The Plan says there is no evidence the enrollee has failed conservative therapy.
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when the enrollee has completed conservative therapy. The file does not show that the enrollee has failed conservative therapy. Therefore, we decided that the Plan does not have to pre-approve an intermittent limb compression device.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve arthroscopy, knee, surgical; with meniscectomy (medial and lateral, including any meniscal shaving (CPT code 29880).
You asked the Plan to pre-approve the service. You say that you are hurting. The Plan denied your request. The Plan says this is to help treat the tear in your knee. The Plan states that your doctor's notes do not show you have tried and failed plan-approved care. The Plan states your doctor's notes show you have signed up for physical therapy and your doctor's notes do not show there is a follow-up for the results of physical therapy. The Plan states they do not know if this surgery will help you until they receive this information; therefore, the surgery is not considered 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 service. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found 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 arthroscopy, knee, surgical; with meniscectomy (medial and lateral, including any meniscal shaving) CPT code 29880 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 the service have not been met. Therefore, we decided that the Plan does not have to pre-approve arthroscopy, knee, surgical; with meniscectomy (medial and lateral, including any meniscal shaving (CPT code 29880).
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pay for the surgical procedures provided on January 26, 2021.

You asked the Plan to pay for muscle, myocutaneous, or fasciocutaneous flap; trunk (15734,15734-59). You say that the Plan should pay this claim. The Plan denied your request. The Plan says that the procedures are not supported in the medical records submitted.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. 

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan has submitted an illegible Hospital Operative Report. Therefore, we decided that the Plan has to pay for the surgical procedures provided on January 26, 2021.

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: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency department visit provided on January 1, 2021, at a CPT code 99285 level of care.
You asked the Plan to pay for the emergency department visit at a CPT code 99285 level of care. You say that the medical records support CPT code 99285 as per CMS guidelines. The Plan denied your request. The Plan says the claim does not meet criteria for CPT code 99285 and is paid at CPT code 99282 level.
The Plan follows Medicare billing and payment rules. The rules say that codes billed must accurately reflect the services provided. In this case, you billed CPT code 99285. The definition of CPT code 99285 is an emergency room visit for the evaluation and management of a patient which requires three components (taking into account the urgency of the clinical condition or the patient's mental status):
1. a comprehensive history; 2. a comprehensive examination; and 3. medical decision making of high complexity. In addition, CPT code 99285 usually includes a presenting medical problem of high severity and immediate significant threat to life or physiologic function. 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 emergency department visit at a CPT code 99285 level of care. Our reviewer says that the service was of moderate severity. Our reviewer found the documentation submitted was reviewed and does not meet criteria. The emergency room visit supports a comprehensive history and exam, medical decision making of moderate complexity due to, amount and complexity of data reviewed, and moderate risk of complications. Therefore, documentation does not support CPT code 99285. 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 emergency department visit at a CPT code 99285 level of care have not been met. Therefore, we decided that the Plan does not have to pay for the emergency department visit provided on January 1, 2021, at a CPT code 99285 level of care.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Tirosint 88 mcg capsule.
You asked the Plan to pre-approve Tirosint. You say that this request is medically necessary. The Plan denied your request. The Plan says this drug 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 Tirosint 88 mcg capsule.
Benefits for Tirosint 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: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the inpatient readmission services provided from October 8, 2020, to October 22, 2020.
You asked the Plan to pay for the inpatient readmission services. The Plan denied your request. The Plan says that the hospital did not provide sufficient information to allow a reasonable conclusion that the second admission was not preventable.
The Plan follows Medicare rules. Medicare rules say that readmissions are denied if the readmission was medically unnecessary; and/or If the readmission resulted from a premature discharge from the same hospital. 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 readmission services. Our reviewer says that the readmission was medically necessary. Our physician reviewer found the enrollee was discharged when considered medically stable on October 22, 2020. Our reviewer also found that the readmission did not result from a premature discharge from the same hospital.
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 inpatient readmission services have been met. Therefore, we decided that the Plan has to pay for the inpatient readmission services provided from October 8, 2020, to October 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the second opinion to be provided by an out-of-network provider.
You asked the Plan to pre-approve the second opinion. You say that you would receive better treatment from this provider due to your current Ophthalmologist not providing a clear explanation of your condition. The Plan denied your request. The Plan says there are providers available that can and are ready to provide the care at this time.
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 second opinion to be provided by an out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genicular nerve blocks (procedure code 64450).
You asked the Plan to pre-approve genicular nerve blocks. You say that the enrollee has tried conservative treatments with no relief. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this procedure is considered to be experimental and investigational.
The Plan must follow Medicare rules. Medicare rules say that genicular nerve blocks are considered investigational and are not eligible for coverage. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of genicular nerve blocks have not been met. Therefore, we decided that the Plan does not have to pre-approve genicular nerve blocks (procedure code 64450).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve conversion of sleeve gastrectomy to gastric bypass.

You asked the Plan to pre-approve the gastric bypass conversion. You say that this procedure is medically
necessary to help the enrollee's weight loss. The Plan denied your request. The Plan says the criteria for the
requested procedure are not met in this case.

The Plan follows Medicare rules. Medicare rules say that repeat bariatric surgery is generally not medically
reasonable and necessary without specific documentation to support the need.

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 gastric bypass conversion. Our
reviewer says that the requested procedure is not shown to be medically reasonable and necessary based on
Medicare guidelines. Our physician reviewer found the enrollee had a previous sleeve gastrectomy that resulted
in weight loss. Following a car accident in 2018 and arthritis that limited the ability to exercise, the enrollee has
gained weight and now has a body-mass index (BMI) of over 44. She has gastroesophageal reflux that is
controlled on medication. The enrollee has attempted dietary weight loss measures. The enrollee has received
psychological clearance.

The documentation submitted does not demonstrate clinical circumstances that a bypass procedure would result in a significant change in the enrollee's condition given the totality of the record. The requested procedure is not medically necessary and reasonable, as defined by Medicare rules, for the enrollee's specific clinical scenario. The elements of the coverage criteria are not satisfied. 

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 gastric bypass conversion have not been met. Therefore, we decided that the Plan does not have to pre-approve conversion of sleeve gastrectomy to gastric bypass.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110).
You asked the Plan to pre-approve the complete maxillary denture. You say that you never received dentures before, and the information the Plan received is fraudulent. The Plan denied your request. The Plan says this service is allowed one time in 5 calendar years. The Plan also says that you have already had this service within the past 5 years and have reached the limit for this 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, complete maxillary denture (D5110) is limited to 1 per 5 calendar years. The record shows that you received a complete maxillary denture (D5110) on December 5, 2020 and your maxillary denture benefit has been exhausted. Therefore, we decided that the Plan does not have to pre-approve a complete maxillary denture (D5110).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay additionally for the dental services with dental codes (D2392, D1206, D4355, and D1999) provided on April 5, 2021.
You asked the Plan to pay additionally for dental codes D2392, D1206, D4355, and D1999. You say that you would like the Plan to reconsider your request. The Plan denied your request. The Plan says dental codes D2392 and D1206 were provided by an out-of-network provider and you are responsible for any amount greater than the payment made by the Plan to the provider. Dental codes D4355 and D1999 are not covered under the Plan's supplemental dental 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, dental codes D2392 and D1206 were provided by an out-of-network provider and you are responsible for any amount greater than the payment made by the Plan to the provider. Dental codes D4355 and D1999 are not covered under the Plan's supplemental dental benefit. Therefore, we decided that the Plan does not have to pay additionally for the dental services with dental codes (D2392, D1206, D4355, and D1999) provided on April 5, 2021.