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

We decided that the Plan does not have to pre-approve out of network (OON) office visits.

You asked the Plan to pre-approve the OON office visit services. You say that you have been suffering with spinal issues for years and need to see this OON provider. You say that you have had 2 spinal surgeries and that you are tired of taking morphine. You say that you had failed surgery. The Plan denied your request. The Plan says there is no medical need shown as to why the enrollee cannot get the office visits from a provider within the plan network.

Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan providers available to meet enrollees' needs. Your contract with the Plan says that, with few exceptions, you must use contract providers for care.

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 OON office visit services. Our reviewer says that the criteria for coverage of OON care have not been met. Our physician reviewer found the Plan's denial is medically justified on the basis that it is offering adequate care to meet the enrollee's medical needs through referral to an in-network provider. There is not anything unique about the enrollee's condition that would make it medically necessary for him to see the requested out-of-network provider. The plan has shown that they have in-network providers who meet the Standards of Care required for treatment of the enrollee's condition.

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 OON office visit services have not been met. Therefore, we decided that the Plan does not have to pre-approve out of network (OON) office visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a neuromuscular stimulator electric shock unit (E0745).

You asked the Plan to pay for the neuromuscular stimulator. You say that the claim should be paid. The Plan denied your request. The Plan says the record shows that documentation submitted did not include an itemized shipping/billing order to indicate the specific supplies or proof of delivery.

The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. 

The record does not contain a valid itemized shipping/billing order to indicate the specific supplies or proof of delivery which support medical necessity for the supplies provided in this case. Without these, the billed supply code cannot be verified. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for a neuromuscular stimulator electric shock unit (E0745).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for
the enrollee.

You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your
request. The Plan says the services can be safely received in other settings.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee
was admitted for surgical treatment of a hip fracture after a fall. Medical problems are stable. There are no
complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided 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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Arthrodesis (22558, 22612), Anterior Segmentation (22845) and Insertion of interbody biomechanical device (22853) for the enrollee.

You asked the Plan to pre-approve these services. You say that the enrollee's condition is affecting his quality of life. The Plan denied your request. The Plan says that the requested service is supported if the enrollee has never smoked.

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. There is no documentation of smoking cessation. The patient has a history of recent smoking. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these 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 Arthrodesis (22558, 22612), Anterior Segmentation (22845) and Insertion of interbody biomechanical device (22853) for the enrollee.
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 this is medically necessary. The Plan denied your request. The Plan says that this is not covered by Medicare.

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 an upright stand-up walker.

You asked the Plan to pre-approve the walker. You say that this is medically necessary, as the walker you received was for a shorter person. The Plan denied your request. The Plan says this 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 the walker. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the medical records provided are insuffiicient to determine whether the elements of coverage criteria are satisfied. In this case, you have osteoarthritis of the knees. The records do indicate that you already have a standard walker. The records do not indicate that the current walkers does not meet your needs. The walker can be adjusted for an individual up to 6 feet, 2 inches tall. The record does not support the medical reasonableness and necessity of the specific walker requested. 

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 walker have not been met. Therefore, we decided that the Plan does not have to pre-approve an upright stand-up walker.
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 a necessity for you. The Plan denied your request. The Plan says rules for SNF care have not been met because the requested services are 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 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 you have no identifiable skilled nursing service needs or skilled therapy service needs. You do not require either skilled nursing or therapy services on a daily basis. As a practical matter, you do 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve image-guided radiation therapy (IGRT).
You asked the Plan to pre-approve IGRT. You say that the enrollee is being treated post-operative and this will have less potential impact on optimal healing. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because IGRT is not considered medically necessary for the enrollee's diagnosis.
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 IGRT. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found for radiation in the palliative setting, IGRT could be considered medically necessary when it is necessary to escalate the dose (such as oligometastases), particularly when using very high dose per fraction, or when critical normal tissues abutting the target necessitate daily image guidance to allow minimal planning margins to spare the normal tissue. In this case, the intent is clearly palliative, and it is not clear what benefit IGRT would afford. It seems as though IGRT is simply being used as routine practice, as there does not seem to be any exceptional circumstances with this enrollee necessitating IGRT. The rationale about patient anxiety about risks of treatment does not seem to be a legitimate rationale for offering treatment that is not considered to be an accepted standard. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IGRT have not been met. Therefore, we decided that the Plan does not have to pre-approve image-guided radiation therapy (IGRT).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve anticancer treatment with Erbitux (J9055) and Nivolumab (J9299).
You asked the Plan to pre-approve Erbitux and Nivolumab. You say that the requested treatment is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for anticancer treatment have not been met because the requested drugs are prescribed for an off-label and medically unsupported use.
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 Erbitux and Nivolumab. Our reviewer says that the requested treatment is not medically necessary. Our physician reviewer found that the requested use of Erbitux and Nivolumab is not FDA-approved for the enrollee's diagnosis. The use 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 Erbitux and Nivolumab have not been met. Therefore, we decided that the Plan does not have to pre-approve anticancer treatment with Erbitux (J9055) and Nivolumab (J9299).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the myocardial perfusion imaging (78452), stress test
(93015), the Regadenoson injection (J2785), and the Technetium tc-99m tetrofosmin (A9502) rendered by the
out of network (OON) provider on May 1, 2020.

You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of
network provider, without prior authorization.

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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided 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 for the myocardial perfusion imaging (78452), stress test (93015), the Regadenoson injection (J2785), and the Technetium tc-99m tetrofosmin (A9502) rendered by the out of network (OON) provider on May 1, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the requested care is a necessity for you. The Plan denied your request. The Plan says rules for IRF care have not been met.
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 that you do not require the intensity of services provided at an IRF. Specifically, you have not been 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-approve IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for therapeutic parenteral drug, single administration (D9610), provided on November 2, 2020.

You asked the Plan to pay for therapeutic parenteral drug. You say that the service was medically necessary. The Plan denied your request. The Plan says the service is not a covered benefit.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Specifically, the service provided is not listed in the Plan's benefits, and therefore, is not covered. Therefore, we decided that the Plan does not have to pay for therapeutic parenteral drug, single administration (D9610), provided on November 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services (CPT 97110) provided to the enrollee on August 28, 2020.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says this code is not appropriate for the service billed.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

In this case, the CPT Code Manual definition of code 97110 is "Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility." 

We asked our coding 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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our coding reviewer found the therapy visit was performed by a physical therapy assistant. Physical therapy assistants are considered Technical and should report services with the appropriate Healthcare Common Procedural Coding System (HCPS) code.

We looked at this coder'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 pay for physical therapy services (CPT 97110) provided to the enrollee on August 28, 2020.
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 for the enrollee. The Plan denied your request. The Plan says this service is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve this service. Our reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our physician reviewer found that the Vertiflex device remains 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone replacement graft for ridge preservation-per site for tooth #6 (CPT code D7953).

You asked the Plan to pre-approve the dental services. You say that this service needs to be done to be able to get dentures and extractions. You state you are currently in pain and the periodontist advised that you need to get the bone replacement done to keep your tooth in place. The Plan denied your request. The Plan says the service is not a covered benefit under the plan.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. This service is not listed in your EOC as a covered benefit; therefore, it is not covered. Therefore, we decided that the Plan does not have to pre-approve bone replacement graft for ridge preservation-per site for tooth #6 (CPT code D7953).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa (J7323).
You asked the Plan to pre-approve Euflexxa. The Plan denied your request. The Plan says the information submitted does not meet the Plan's medical necessity guidelines for coverage.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 Euflexxa. Our reviewer says that Euflexxa (J7323) is not medically reasonable and necessary for the enrollee. Our physician reviewer found the Plan requires that other forms of Hyaluronic acid injections be used. There is no evidence that the enrollee is allergic to or intolerant of these other forms of Hyaluronic acid. Our reviewer found that there is no evidence that the enrollee has tried and not responded to these other forms of Hyaluronic acid injections. Our physician reviewer also found that there is no documentation as to why these other forms of Hyaluronic acid would not be expected to be safe and effective for the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have to pre-approve Euflexxa (J7323).