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

We decided that the Plan does not have to pre-approve lumbar/sacral facet joint radio frequency neurolysis (64635).You asked the Plan to pre-approve the lumbar/sacral facet joint radio frequency neurolysis. You say that you have done all that is required with your previous doctor and you request review with all the previous notes.The Plan denied your request. The Plan says this request does not meet medical necessity standards.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 lumbar/sacral facet joint radiofrequency neurolysis. 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 received RFA of his facets in the past but the degree and duration of pain relief is not documented. Therefore, the request does not meet the requirements of the LCD and therefore, the request is deemed not medically reasonable or necessary.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the lumbar/sacral facet joint radio frequency neurolysis have not been met.Therefore, we decided that the Plan does not have to pre-approvelumbar/sacral facet joint radio frequency neurolysis (64635).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe chest x-ray rendered on January 13, 2020.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the claim is a duplicate.The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied.We looked at the file and Medicare rules. The file shows that the services at issue were previously paid by the Plan on a separate claim for the same date of service. 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 pay forthe chest x-ray rendered on January 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider on December 18, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says there is no network deficiency for these services.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 nota network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. 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 forthe medical services provided to the enrollee by an out-of-network provider on December 18, 2019.
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 enrollee can tolerate 3 hours of therapy a day,
and is highly motivated. The Plan denied your request. The Plan says the complexity of the enrollee's rehab
needs does not warrant the intensity or level of care that only an IRF can provide.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described above.
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 physician reviewer found
that the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital
inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's current medical status
and medical conditions do not require intensive physician or nursing oversight in an IRF. He may benefit from
additional multiple therapies, however, his functional level at this time does not require or indicate that this
therapy must be in an IRF with an intensive level program. Wheelchair training does not require an IRF
admission. His leg weakness, likely from nerve compression due to stenosis, will not improve faster with acute
inpatient therapy vs a lower level of care. There is no indication that the enrollee's rehabilitation needs will not
be able to be effectively 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Levitation knee braces (powered knee braces). You asked the Plan to pre-approve Levitation knee braces. You say that you are in dire need of these braces.The Plan denied your request. The Plan says the denial of authorization for these items is correct, because there is not enough peer reviewed data on the safety and effectiveness of the requested brand of equipment.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 Levitation knee braces. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not reveal that your physician specifically indicates that this brand of knee braces is medically necessary. The literature does not support sufficient evidence that this brand of brace is effective for your condition. Furthermore, there is no indication of objective imaging studies of osteoarthritis or imaging or objective examination findings of significant knee instability. Therefore, this specific brace appears to exceed your medical 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 Levitation knee braces have not been met.Therefore, we decided that the Plan does not have to pre-approve Levitation knee braces (powered knee braces).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea referral to an out-of-network physical therapy provider.You asked the Plan to pre-approvethese services. You say that the in-network provider is further from your residence.The Plan denied your request. The Plan says the services are available from network providers.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. The Plan confirmed that the in-network provider is located within 14 miles of your residence, which is an acceptable distance per Medicare rules. 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-approvea referral to an out-of-network physical therapy provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay foran electrocardiogram (93010) provided on December 17, 2019.You asked the Plan to pay forthe electrocardiogram. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says the records submitted do not support CPT code 93010 as they appear to be incomplete.The Plan must follow Medicare rules. Medicare rules say that a professional component billing based on a review of the findings of these procedures, without a complete, written report similar to that which would be prepared by a specialist in the field, does not meet the conditions for separate payment of the service.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the electrocardiogram have not been met. Specifically, the records submitted do not include a complete, written report in regards to the electrocardiogram.Therefore, we decided that the Plan does not have to pay foran electrocardiogram (93010) provided on December 17, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Avastin.You asked the Plan to pre-approve Avastin. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested drug is not a covered benefit.The Plan must follow Medicare rules. Medicare rules say that routine costs related to clinical trials is the responsibility of Original Medicare. We looked at the file and Medicare rules. Review of the file shows that the enrollee is enrolled in a clinical trial. Therefore, the request for Avastin is related to the clinical trial. Based on this information, we decided that Medicare rules for coverage of Avastin have not been met.Therefore, we decided that the Plan does not have to pre-approve Avastin.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF 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 Medicarerules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan wascorrect 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 was limited by acute on chronic back pain. The enrollee requires maximum assistance with transfers. The enrollee was unable to fully stand due to pain. The documentation does not support that the complexity of the enrollee's nursing, medical and rehabilitation needs require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not support that the enrollee would be fully able to participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility.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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveintravenous (IV) Stelara.You asked the Plan to pre-approve IV Stelara. The Plan denied your request. The Plan says there is no current dosing information for IV Stelara.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 looked at the file, and Medicare rules. There is no IV compatibility for the requested drug. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pre-approve intravenous (IV)Stelara.Benefits for subcutaneous Stelara 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: 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 physical therapy services. 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. 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 physical therapy 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 you have a history of a total knee replacement. The
requested supervised physical therapy beyond what the health plan approved would be excessive and is
generally not accepted as specific and effective therapy for your condition. You are already participating in a
home exercise program and do not require additional supervised therapy beyond what the health plan approved.
You can continue to work on range of motion exercises on your own and you are performing daily walking
activities on his own already. The records do not demonstrate that ongoing therapy is needed with the unique
skills of a professional therapist are required to safely and effectively provide treatment, that the services can
be safely and effectively performed only by a therapist, or under the supervision of a therapist. The requested
services are not part of a maintenance program, and the specialized skill, knowledge and judgment of a
qualified therapist are not required to establish, design and/or deliver a program to maintain the patient's current
condition or to prevent or slow further deterioration.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of physical therapy services have not been met. Therefore, we decided that the
Plan does not have to pre-approve additional physical therapy services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve varicose vein treatments.You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the information does not indicate that weight is low enough.The Plan must follow Medicare rules. Medicare rules say that the treatment of varicose veins are only covered under certain medical indications. We looked at the file and Medicare rules. The documentation provided does not indicate the enrollee's BMI is less than 35. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pre-approve varicose vein treatments.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveadmission to a skilled nursing facility (SNF).You asked the Plan to pre-approveSNF admission. 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 Medicare pays for care in a SNF when the four factors listed above 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 admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee has freezing gait syndrome and was admitted to the hospital for elective cervical-thoracic fusion surgery. The enrollee received oral medications. The enrollee had stable vital signs. The enrollee was treated for pain with effect. The enrollee required contact guard assistance with functional mobility including walking to 125 feet with a rolling walker. The enrolleerequired varying assistance with activities of daily living. The documentation does not support that the enrollee requires the specialized skills, knowledge, or judgment of a skilled professional nurse or qualified therapist to safely and effectively provide medically necessary and reasonable treatment. The documentation does not support that skilled nursing or skilled therapy services are required on a daily basis. As a practical matter, the enrollee does not require the necessary services on an inpatientbasis, at a SNF 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 SNF admission have not been met.Therefore, we decided that the Plan does not have to pre-approveadmission to a skilled nursing facility (SNF).
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approvehypogastric plexus nerve block procedure.You asked the Plan to pre-approvehypogastric plexus nerve block procedure. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says that the requested services are not medically necessary.The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 hypogastric plexus nerve block procedure. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found you have chronic pelvic pain. You had hemorrhoid surgery as well as multiple spine surgery. You had a prior diagnostic block which gave you 48 hours of pain relief but you did not get a neurolytic block. You had an intra-thecal pain pump which did not control your pain andit was explanted. Superior hypogastric plexus block is the standard of care to make the diagnosis of neuropathic pelvic pain. Therefore, you 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 hypogastric plexus nerve block procedure have been met.Therefore, we decided that the Plan has to pre-approvehypogastric plexus nerve block procedure.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute IRF admission and services.You asked the Plan to pre-approveIRF care. You say that the enrollee needs close physiatrist supervision and interdisciplinary coordination of care.The Plan denied your request. The Plan says the enrollee does not need three hours a day of therapy,or physician monitoring three times a week.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.We asked our physician reviewer to carefully review thecase file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our physician reviewer found that the enrollee is at moderate assist for sitting up, and minimal assist for standing up, walking using a four-wheel walker, and dressing. The enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation.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-approveacute inpatientrehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecontinued inpatient mental health care starting February 15, 2020.You asked the Plan to pre-approvecontinued inpatient mental health care. You say that the enrollee cannot be treated at a lower level care.The Plan denied your request. The Plan says inpatient care is no longer 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 continued inpatient mental health care. Our reviewer says that the requested inpatient care is not medically necessary. Our physician reviewer found based on the records provided it was not expected this enrollee would improve in a reasonable period of time beyond the dates approved by the Plan as he was not showing any dangerousness to self or others, auditory or visual hallucinations and without aggressive behaviors. It did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the dates in question as he did not have any suicidal or homicidal thoughts, auditory or visual hallucinations or abnormal behaviors. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued inpatient mental health care have not been met.Therefore, we decided that the Plan does not have to pre-approvecontinued inpatient mental health care starting February 15, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that you do not want to enter a skilled nursing facility or return home.The Plan denied your request. The Plan says your needs could be met at a skilled nursing facility.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.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 you do not require the intensity of services provided at an IRF. Specifically, you are not shown to require, or to be able to currently perform, fifteen hours per week of rehabilitative services with regular physician evaluation. Your care needscan 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-approveacute inpatient rehabilitation facility (IRF) admission and services