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

We decided that the Plan does not have to pre-approve a Group 3 standard power wheelchair and accessories.You asked the Plan to pre-approve a Group 3 standard powe rwheelchair and accessories. You say that the enrollee needs a Group 3 standard power wheelchair and accessories to complete basic Mobility Related Activities of Daily Living.The Plan denied your request. The Plan says the enrollee lives in a skilled nursing facility and therefore a Group 3 standard power wheelchair and accessories is not covered by Medicare or the Plan.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home. Records show that a Group 3 standard power wheelchair and accessories is being requested for use in a SNF.Therefore, we decided that the Plan does not have to pre-approve a Group 3 standard power wheelchair and accessories.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lumbar epidural steroid injection (ESI). You asked the Plan to pre-approve the ESI. You say that the enrollee should be allowed to try this ESI to reduce her pain symptoms.The Plan denied your request. The Plan says there is no evidence that the required level of pain relief was achieved from the prior ESI.The Plan follows Medicare rules. Medicare rules say that ESIs are covered for enrollees with certain types of spinal pain when conservative treatments have failed. Repeat ESI is covered when a prior treatment provided at least 50% pain reduction for at least six weeks.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 ESI. Our reviewer says that the requested ESI is not considered medically reasonable and necessary in this case. Our physician reviewer found he enrollee is a 71 year old female with a history of lumbar radiculopathy and disc disease at L2-3, L4-5,L5-S1 and lumbar spondylosis with baseline pain rated at 8 to 9/10. The member underwent a right sided L4 and L5 transforaminal epidural steroid injection (TFESI) on 7/8/2019. Her post-procedural pain scale was noted 8.5/10. On return to the clinic on 8/22/19, the member rated her pain as 7 to 8/10.The member had several additional office visits with pain related as follows: 9/12/19 the pain was 9/10/19; 9/26/19 -8/10; 10/24/19 -8/10. The member's provider has requested a repeat L4 and L5 TFESI.The review has determined that there is no objective evidence that the member had the required 50% reduction of pain with the 7/8/2019 TFESI at L4-L5 on the right. The requested TFESI is not 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 the ESI have not been met.Therefore, we decided that the Plan does not have to pre-approve a lumbar epidural steroid injection (ESI).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cytogenomic constitutional (genome-wide) microarray analysis for the enrollee.
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 procedure code 81229 is not covered.
The Plan must follow Medicare rules. Medicare rules say that procedure code 81229 is denied as not medically necessary. The services at issue are cytogenomic constitutional (genome-wide) microarray analysis testing described by code 81229. This code is denied by Medicare as not medically necessary. Therefore, we decided that the Plan does not have to pre-approve cytogenomic constitutional (genome-wide) microarray analysis for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approvephysical therapy services out-of-area.You asked the Plan to pre-approvethe out-of-area physical therapy services.. You say that you need to continue to receive physical therapy while in Florida. You say that your shoulder is still very sore and that you have limited mobility. You say that you have to go to Florida to care for your sick father.The Plan denied your request. The Plan says you must receive your care from a network provider.Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and pre-approved care.  We looked at thefile and Medicare rules. The rules say that urgently needed services are those needed because of an unforeseen illness or condition and it is not reasonable to get the services from the health plan. The records show that the need for out-of-network physical therapy services were not unforeseen prior to leaving the service area, and are therefore not considered to be urgent. Based on this information, we decided that Medicare rules for coverage of out-of-area care have not been met.Therefore, we decided that the Plan does not have to pre-approvephysical therapy services out-of-area.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Zilretta injections to the knees.
You asked the Plan to pre-approve the Zilretta injections. You say that this treatment is indicated for this enrollee. The Plan denied your request. The Plan says this treatment remains experimental at this time.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the Zilretta injections. Our reviewer says that the requested treatment is not considered reasonable and necessary at this time. Our physician reviewer found this enrollee presents with a history of chronic bilateral knee pain. She has been diagnosed with severe bilateral medial compartment osteoarthritis. Under consideration is a request for Zilretta injections to both knees. In this case, there is no clear evidence that the enrollee had failed to improve with recent conservative treatment or was not a surgical candidate. The most recent clinical exam findings and complaints were documented on 10/24/19 with no updates to her current condition provided, and no documentation of her response to the corticosteroid injections performed on 10/24/19. Therefore, the documentation does not support that Zilretta is medically reasonable and necessary or safe and effective for treatment of this enrollee's medical condition 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 the Zilretta injections have not been met. Therefore, we decided that the Plan does not have to pre-approve Zilretta injections to the knees.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve extracorporeal shockwave therapy (ESWT) for treatment of erectile dysfunction (ED).You asked the Plan to pre-approve the ESWT for ED treatment. You say that you feel that you should be allowed to try this treatment as other methods have been ineffective.The Plan denied your request. The Plan says Medicare does not cover the treatment of ED.Please note that the company reviewed the denial rationale from the Plan and we find that there is no Medicare non-coverage of treatment of ED. However, our decision is in regards to whether this particular treatment for ED is 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 ESWT for ED treatment. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found although preliminary results appear promising, additional well-designed studies with long-term follow-up are needed to establish safety and effectiveness of ESWT for the treatment of ED. Study limitations are short-term follow-up and small sample size. Additional data are needed to confirm the efficacy suggested by these results. As such, the requested shock wave therapy is considered experimental/investigational 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 the ESWT for ED treatment have not been met.Therefore, we decided that the Plan does not have to pre-approve extracorporeal shockwave therapy (ESWT) for treatment of erectile dysfunction (ED).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hospital bed, semi-electric (head and foot adjustment), with any type side rails, with mattress (E0260).You asked the Plan to pre-approve the hospital bed. You say that you are requesting review of denial of services.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 hospital bed have not been met. You have multiple medical conditions including COPD. You have no history of congestive heart failure. There is no order or documentation within the medical records for a semi-electric hospital bed. The physical exam does not support a medical necessity or the assessment and plan for you. You have no history of congestive heart failure. No rationale for head of the bed elevation, no use of electrical equipment needing attachment to a hospital bed. There is no documentation of a position that you need to be in that is not possible with a regular bed. There is no change in body position that requires a hospital bed. There is no evidence for the of use of traction.Therefore, we decided that the Plan does not have to pre-approve hospital bed, semi-electric (head and foot adjustment), with any type side rails, with mattress (E0260).
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve Addition to lower extremity, below knee, acrylic socket.You asked the Plan to pre-approve Addition to lower extremity, below knee, acrylic socket (L5629). You say that this Addition is for a definitive prosthesis.The Plan denied your request. The Plan says that the socket is not reasonable and necessary for an initial or preparatory prosthetic.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 not provided a valid denial rationale for L5629 for use with a final L5301 below knee prosthesis. Therefore, we decided that the Plan has to pre-approve Addition to lower extremity, below knee, acrylic socket.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvecervical radiofrequency ablation (RFA) of the facet joint nerves.You asked the Planto pre-approvethe RFA procedure. You say that it is felt that a repeat RFA procedure is necessary to treat the enrollee's pain.The Plandenied your request. The Plansaysthe enrollee has had the maximum number of RFA procedure for the current 12 month period.The Plan must follow Medicare rules. Medicare rules say that RFA procedures in the cervical spine will not be covered more than twice within a rolling 12 month period.In the 12 month period beginning with the first RFA on January 14, 2019, the enrollee has a second RFA on October 30, 2019. No further RFA procedures can be covered until beyond January 14, 2020. At the time of this request (11/8/2019), coverage rules for the requested services are not met.Therefore, we decided that the Plandoes not haveto pre-approvecervical radiofrequency ablation (RFA) of the facet joint nerves.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea shower chair.You asked the Plan to pre-approvea shower chair. You say that you have spine and feet issues. You say that the shower chair is a medical necessity for you because you cannot walk and are afraid that you may fall in thebathroom.The Plan denied your request. The Plan says this item is not a covered benefit.The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item.Therefore, we decided that the Plan does not have to pre-approvea shower chair.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea Superion spacer.You asked the Plan to pre-approvethese 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 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 services are not medically necessary. Ourphysician reviewer found the enrollee has low back pain. The Superion spacer is considered experimental, as more research is needed. The services are 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-approvea Superion spacer.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional physical therapy services.You asked the Plan to pre-approve the services. You say that this is medically necessary.The Plan denied your request. The Plan says there is no indication that the twenty four previous visits have improved function.The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found in this case, there is no indication prior PT has served to provide sustained, significant improvement in pain and/or function and there is no indication residual deficits could not be addressed via a home exercise program.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plan does not have to pre-approve additional physical therapy services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6545.
You asked the Plan to pre-approve the compression stockings. You say that your doctor recommended compression stockings. The Plan denied your request. The Plan says you do not have any ulcers or wounds.
The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6545 are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that compression bandages and gradient compression wraps are covered only when they are used as dressings over a qualifying wound. The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you do not have a medical condition for which compression stockings can be covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6545.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve magnetic resonance imaging (MRI) of the left shoulder.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. Medicare rules say that MRIs are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are medically necessary. Our physician reviewer found the submitted records show that you have left shoulder pain and weakness several months after a fall. The physical examination confirms shoulder weakness. The notes say the symptoms have not responded to non-steroidal anti-inflammatory drugs (NSAIDs) or an acute steroid injection. Plain x-rays do not note bone injury. The MRI would likely aide in diagnosis and treatment decisions and is reasonable and medically necessary 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 magnetic resonance imaging (MRI) of the left shoulder.If the Plan does not agree with our decision,they can ask us to open a case again. We only open acase 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: 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 your doctor wants you to have a total electric hospital bed.The Plan denied your request. The Plan says total electric hospital beds are not covered by Medicare or the Plan.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-approvefoot orthotics.You asked the Plan to pre-approvefoot orthotics. You say that your doctor recommended orthotics because of your knee pain.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-approvefoot orthotics.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hyperbaric oxygen therapy for the enrollee.
You asked the Plan to pre-approve the therapy. You say that this is medically necessary. The Plan denied your request. The Plan says a diagnosis of sudden hearing loss is not eligible for this treatment.
The Plan must follow Medicare rules. Medicare rules say that hyperbaric oxygen therapy is covered for specific indications. 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 therapy. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found according to the criteria, hearing loss is not listed as a covered diagnosis for this treatment.
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 therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve hyperbaric oxygen therapy for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Entyvio (J3380). You asked the Plan to pre-approve Entyvio. You say that the requested medication is necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.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 Entyvio. Our reviewer says that the medication is not medically necessary. Our physician reviewer found the enrollee is noted to have collagenous colitis, for which she previously took medicine. After stopping the medicine, the enrollee experienced an increase in colitis symptoms. Documentation indicates that the enrollee was to resume the medicine and undergo laboratory testing. There is no documentation of a re-evaluation indicating the enrollee's response to the resumption of the medicine or the provider's interpretation of the laboratory results. There is no documentation of a repeat colonoscopy, new biopsy or change in diagnosis. There is no documentation of a plan to order Entyvio, just an order for the drug. As such, the documentation does not support that the requested drug is medically necessary or reasonable.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Entyvio have not been met.Therefore, we decided that the Plan does not have to pre-approve Entyvio (J3380).