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

We decided that the Plan does not have to pre-approve an osteogenesis stimulator (E0748).

You asked the Plan to pre-approve an osteogenesis stimulator. You say that the requested item is a medical
necessity for you. The Plan denied your request. The Plan says rules for coverage for an electrical bone growth
stimulator have not been met.

The Plan must follow Medicare rules. The rules say that an electrical bone stimulator is covered when the
criteria in the Medicare rules section have been met.

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 an osteogenesis stimulator. Our
reviewer says that the requested item is not medically reasonable and necessary in this case. Our physician
reviewer found that detailed documentation is not evident regarding failed spinal fusion where a minimum of 9
months has elapsed since the last surgery; following a multilevel spinal fusion surgery; or, following spinal
fusion surgery where there is a history of a previously failed spinal fusion at the same site. The coverage
criteria accepted by Medicare are not met. There is no compelling rationale presented or extenuating
circumstances noted to support the medical necessity of this request as an exception to the criteria.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of an osteogenesis stimulator have not been met. Therefore, we decided that the
Plan does not have to pre-approve an osteogenesis stimulator (E0748).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (95955, 95908, 95885, 95927) provided on December 21, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services cannot be verified.
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 95955 is "Electroencephalogram (EEG) during nonintracranial surgery (eg, carotid surgery)". The CPT Code Manual definition of code 95908 is "Needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; limited (List separately in addition to code for primary procedure)". The CPT Code Manual definition of code 95885 is "Nerve conduction studies; 3-4 studies". The CPT Code Manual
definition of code 95927 is "Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in the trunk or head". We asked our coder 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 use of codes 95955, 95908, 95885, and 95927 is not supported by the records provided. Our reviewer found that for CPT 95955, the procedure report documents real time EEG monitoring, and would be included in the neuromonitoring code, and therefore would not be covered. For CPT 95908, the procedure report does not support nerve conduction studies, as pedicle testing is not baseline nerve conduction studies. For CPT 95885, the procedure report does not document nerve conduction study, as pedicle testing is not baseline nerve conduction studies, therefore this procedure would not be covered. For CPT 95927, the procedure report does not document stimulation recording in the trunk or head. Therefore, this procedure cannot be confirmed as performed. 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 the services (95955, 95908, 95885, 95927) provided on December 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on March 18, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this provider is not Medicare certified.
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program.
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for the services provided on March 18, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says experimental and investigational procedures are not covered by Medicare. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found there is a lack of large volume, long-term peer-reviewed outcome studies to support the use of this 
device for this enrollee's medical condition. FDA indications include implantation of the Superion device at 
one or two adjacent lumbar levels in patients with moderate spinal stenosis in whom operative treatment is 
indicated at no more than two levels, from L1 to L5. This enrollee has multiple degrees of spinal stenosis, 
many not at FDA indicated levels of "moderate" spinal stenosis (including the planned levels of implantation 
L4-S1.)  A formal imaging study was not provided for review. FDA contraindications include spinal instability, 
scoliosis, obesity, and osteoporosis, which have not been adequately addressed in the medical records. There is 
no discussion of spinal instability on flexion/extension films. There is discussion of scoliosis. 

There is no discussion indicating that a DEXA scan has demonstrated the lack of significant osteoporosis in 
this patient. 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 Vertiflex Superior 
interspinous device 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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Vertiflex device for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable home ventilator (E0466).

You asked the Plan to pre-approve a portable home ventilator. You say that the requested item is needed in preference to a bi-level positive airway pressure (BiPAP) device. The Plan denied your request. The Plan says rules for coverage have not been met because the requested item is not medically necessary.

The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. The rules also say that the decision to use a ventilator or a bi-level positive airway pressure device is made based upon the specifics of each person's medical condition.

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 portable home ventilator. Our reviewer says that the requested item is not medically reasonable and necessary in this case. Our physician reviewer found that you have diagnoses of obesity-hypoventilation syndrome (OHS) and chronic obstructive pulmonary disease (COPD) with chronic hypercapnic respiratory failure. Pulmonary function test results are not provided but the clinical notes indicate that your carbon dioxide (CO2) retention is felt to be primarily caused by OHS. Medicare does not cover a home ventilator in the treatment of this condition. Continuous positive airway pressure (CPAP) or bi-level positive airway pressure (BiPAP) are the appropriate treatments and alarms and backup batteries are not needed for this indication. Certain BiPAP devices are able to provide the average volume assured pressure support (AVAPS) mode of support, and Medicare does not cover a ventilator when used as BiPAP.

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 portable home ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a portable home ventilator (E0466).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the implantation of a spinal cord stimulator (63650).

You asked the Plan to pre-approve the implantation of a spinal cord stimulator. You say that this is a covered service. The Plan denied your request. The Plan says the requirements for coverage have not been met.

The Plan follows Medicare rules. Medicare rules say that spinal cord stimulators may be covered as therapy for relief of chronic intractable pain, provided that there has been a demonstration of pain relief with a temporarily implanted electrode precedes permanent implantation. 

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 implantation of a spinal cord stimulator. Our reviewer says that the requested spinal cord stimulator is not shown to be medically necessary in this case. Our physician reviewer found there is no documentation of the results of a spinal cord stimulator trial. More information is needed to show that the requirements for coverage have been met. 

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 implantation of a spinal cord stimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve the implantation of a spinal cord stimulator (63650).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee meets LTACH admission criteria. The Plan denied your request. The Plan says the enrollee is receiving appropriate in-patient acute care, is presently clinically unstable, and does not require transfer to a LTACH.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation provided indicating medical necessity for LTACH services. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and
effectively only on an inpatient basis. 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for acute inpatient rehabilitation facility (IRF) admission and
services.

You asked the Plan to pay for IRF care. You say that you need these services and feel a skilled nursing facility
would be more harmful than helpful. The Plan denied your request. The Plan says the criteria for an IRF are not
met. The necessary services can be provided in a lower level of care.

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 pay for 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 the complexity of your nursing, medical and rehabilitation needs does not require
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the
documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that you 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 pay for acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is ready and stable for a 
transfer to an LTACH. The Plan denied your request. The Plan says LTACH services are not medically 
necessary. The enrollee is currently not required to discharge elsewhere to receive ongoing acute level care. As 
acute care hospitals and LTACHs are licensed to provide the same level of care, there is no advantage in 
moving the enrollee from the current acute care facility to an LTACH setting. All services that would be 
provided in the LTACH are being provided in the current acute care setting, which is already approved. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.  
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no documentation provided indicating medical necessity for LTACH 
services. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not 
require services at the LTACH that are not available and covered at the acute care hospital where he/she is 
currently receiving care. There are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the health plan. The requested LTACH services are not 
medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be 
furnished safely and effectively only on an inpatient basis. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) to be provided by 
an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve MRI. You say that your doctor told you he cannot treat you without this 
test. The Plan denied your request. The Plan says the denial of authorization for this test is correct, because this 
provider is out-of-network with the Plan and this MRI can be performed by an in-network provider. 
 
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 
magnetic resonance imaging (MRI) to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a second opinion consultation to be provided by an outof-
network (OON) provider.
You asked the Plan to pre-approve specialist visit. You say that you saw an in-network doctor and were
misdiagnosed, so you would like to get a second opinion. The Plan denied your request. The Plan says the
denial of authorization for this service is correct, because this provider is out-of-network with the Plan and you
can receive a second opinion visit from an in-network specialist.
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
a second opinion consultation to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on March 26, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this provider is not Medicare certified.
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program.
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for the services provided on March 26, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (0031U, 0032U, 81225, 81226, 81227, 81230, 81231, 81240, 81241, 81291, 81328, 81355, 81401, 81479) provided September 24, 2020.
You asked the Plan to pay for laboratory services. You say that this is supported in the records. The Plan denied your request. The Plan says this was not billed with the correct place of service.
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS). We looked at the file and Medicare rules. The testing at issue was billed with POS 81 for an independent laboratory, but the record shows that the sample was not taken in the laboratory. Based on this information, we decided that Medicare rules for coverage of laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services (0031U, 0032U, 81225, 81226, 81227, 81230, 81231, 81240, 81241, 81291, 81328, 81355, 81401, 81479) provided September 24, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xeljanz (J8499).
You asked the Plan to pre-approve Xeljanz. You say that the enrollee has already tried and failed Humira. The
Plan denied your request. The Plan says Xeljanz is not covered under the enrollee's plan under any normal
circumstances. The Plan also says that outpatient prescription drugs are not covered by the Plan.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 Xeljanz (J8499).
Benefits for Xeljanz 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.

You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the request for the continued skilled nursing level of care exceeds the medical needs.

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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for continued 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.