Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve placement of the CardioMEMs pulmonary artery pressure monitor.

You asked the Plan to pre-approve the CardioMEMs procedure. You say that the requested device is medically necessary. The Plan denied your request. The Plan says there is no evidence of an approved investigational device exemption (IDE) study.

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 CardioMEMs procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found therapy change based on data obtained from a CardioMEMs device has been demonstrated in only one randomized prospective trial to help reduce hospital readmission compared to standard medical therapy. Moreover, concerns have been raised about potential bias in this trial calling into question the results. Therefore, the efficacy of the CardioMEMS device is uncertain at this time according to leading authorities and not recommended in current guidelines for the treatment of heart failure. Medicare coverage criteria are not met since the device should still be considered experimental or investigational. 

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 CardioMEMs procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve placement of the CardioMEMs pulmonary artery pressure monitor.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve catheter ablation (93656).

You asked the Plan to pre-approve catheter ablation. You say that this service is medically necessary. The Plan denied your request. The Plan says there has been no trial of any antiarrhythmic medication.

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 catheter ablation. 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 support that catheter ablation for the treatment of atrial fibrillation is medically reasonable and necessary for the enrollee in this case. Catheter ablation is a reasonable option for patients when medications fail to adequately control symptoms or are not tolerated. This has not been demonstrated in this case. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of catheter ablation have not been met. Therefore, we decided that the Plan does not have to pre-approve catheter ablation (93656).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc-One injections every 60 days.

You asked the Plan to pre-approve the Synvisc-One injections. You say that it is felt that these injections are necessary. The Plan denied your request. The Plan says the requested Synvisc injections are not considered necessary to be provided every one to two months.

The Plan follows Medicare rules. Medicare rules say that viscosupplementation, like Synvisc-One may be considered reasonable and necessary when certain criteria are 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 the Synvisc-One injections. Our reviewer says that the requested treatment is not considered reasonable and necessary at this time. Our physician reviewer found in this case, this 33-year-old female was being treated for right knee pain and post-traumatic osteoarthritis of the right knee. She is noted with persistent right knee pain. Exam reveals ambulation with prosthesis secondary to left below the knee amputation with antalgic gait noted on the right. X-rays of the right knee dated 12/7/20 notes moderate osteoarthritic changes and joint space narrowing of the medial compartment of the right knee; lateral compartment and patellofemoral joint seem reasonably preserved. However, detailed documentation is not evident regarding trial and failure of recent, reasonable and comprehensive less invasive conservative care measures prior to injection. A trial/failure of aspiration and cortisone injection is not evident. Furthermore, repeat viscosupplementation injections are not indicated unless previous injection has provided benefit. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the requested Synvisc One injections are not medically reasonable and 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 Synvisc-One injections have not been met. Therefore, we decided that the Plan does not have to pre-approve Synvisc-One injections every 60 days.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 5 porcelain crowns (D2740) and 5 core build up (D2950).

You asked the Plan to pre-approve the dental services. You say that the enrollee needs these services. The Plan denied your request. The Plan says porcelain crown is not listed as a covered service. The Plan says that core build up is not listed as a covered service either.

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. Therefore, we decided that the Plan does not have to pre-approve 5 porcelain crowns (D2740) and 5 core build up (D2950).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care beyond
March 6, 2021.

You asked the Plan to pre-approve the continued SNF care. You say that you continue to require 24-hour care
and cannot be released at this time. The Plan denied your request. The Plan says there is no need for continued
daily skilled services. As such, the stay is no longer covered.

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 the continued SNF care. Our reviewer
says that daily skilled services are not necessary. Our physician reviewer found the beneficiary is an 89-yearold
male with acute hypoxic respiratory failure and COVID-19 infection. From a nursing perspective, the
beneficiary received oral medications. The beneficiary had stable vital signs. He was treated for pain with
effect. Regarding rehabilitation services, the beneficiary received physical and occupational therapy in the
SNF. By the dates in question, the beneficiary was at a maximal assist level with functional mobility, and he
was non-ambulatory. The beneficiary required varying assist with daily living activities.

There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs.
This beneficiary does 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 the continued SNF care have not been met. Therefore, we decided that the Plan
does not have to pre-approve continued skilled nursing facility (SNF) care beyond March 6, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that the enrollee meets the full criteria for an IRF stay. You say that a lower level of care cannot provide the total IDT approach needed and the higher intensity therapy is needed. The Plan denied your request. The Plan says the enrollee does not meet the guidelines for coverage of IRF care. The Plan says that the enrollee's needs can be met at a lower, less intensive 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 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 rib pain after a fall. The enrollee's 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 the 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on June 15, 2020 to June 24, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the mammography services (77066, G027) and office visit (99214). You say that you would like reconsideration because you were referred to this oncologist for treatment in 2016. The Plan denied your request. The Plan says you did not receive a referral from your primary care provider 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 not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the medical services provided on June 15, 2020 to June 24, 2020 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Favorable

We decided that the Planhasto pre-approveleft heart catheterization with angiography.You asked the Planto pre-approvethe coronary angiography. You say that the enrollee has progressive chest pain with a history of prior heart attack. This assessment of her heart anatomy is necessary as she is likely have significant coronary artery disease.The Plandenied your request. The Plansaysthatthere is insufficient characterization of chest pain and no details regarding the findings of prior heart attack. Additionally, no stress or other testing was provided.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 the coronary angiography. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found based on the records, the patient hascoronary disease (prior non-ST elevation myocardial infarction), reduced ventricular function, and now worsening exertional chest pain and dyspnea.The symptoms documented appear typical of angina (exertional) and are increasing such that left heart catheterization is reasonable and appropriate.Current guidelines also consider coronary angiography appropriate in this 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 the coronary angiography have been met.Therefore, we decided that the Planhas to pre-approveleft heart catheterization with angiography.If the Plandoes not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/orsend us the new information. This does not happen often. If we decide toopen the case again, we will send you a letter
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plandoes not haveto pay fora comprehensive oral evaluation (D0150) received on September 10, 2020.You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The Plansaysthe service exceeds the frequency limitation in benefit 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. The Plan covers comprehensive oral evaluations (D0150) once every three years.The same service was last received less than three years ago on August 19, 2020. Based on this information, we decided thatthe Plan's rules for coverage of the services have not been met.Therefore, we decided that the Plandoes not haveto pay fora comprehensive oral evaluation (D0150) received
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approveHerceptin.You asked the Plan to pre-approvethese 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. 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 these services. Our reviewer says that the services are medically necessary. Our physician reviewer found the enrollee has a diagnosis of ampullary adenocarcinoma. The treatment of advanced ampulla of Vater canceris based on that for esophageal or gastric cancers. Herceptin plus chemotherapy is a standard first-line treatment for human epidermal growth factor receptor 2 (HER2)-positive advanced esophagogastric cancer. ERBB2 is considered a surrogated marker for HER2. Use is supported by major drug compendia and the medical literature for this indication. The use of Herceptin and Gemzar is reasonable and 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 been met.Therefore, we decided that the Plan has to pre-approveHerceptin.If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide toopen the case again, we will send you a letter.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay fora vertebral corpectomy (63090) and the insertion of an intervertebral biomechanical device (22854) provided on March 16, 2020.You asked the Plan to pay fora vertebral corpectomy and the insertion of an intervertebral biomechanical device. You say that these codes are supported.The Plan denied your request. The Plan says these procedures are not documented.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.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 a vertebral corpectomy and the insertion of an intervertebral biomechanical device. Our reviewer says that these codes are not supported. Our physician reviewer found the submitted medical records do not include sufficient documentation to validate that a vertebral corpectomy (vertebral body resection), partial or complete, transperitoneal orretroperitoneal approach with decompression of spinal cord, cauda equina or nerve root(s), lower thoracic, lumbar, or sacral; single segment was performed on March 16, 2020; therefore, code 63090 cannot be verified.  The records also do not include sufficient documentation to validated that an  insertion of intervertebral biomechanical device(s) (eg, synthetic cage, mesh) with integral anterior instrumentation for device anchoring (eg, screws, flanges), when performed, to vertebral corpectomy(ies) (vertebral body resection, partial or complete) defect, in conjunction with interbody arthrodesis, each contiguous defect (List separately in addition to code for primary procedure), so 22854 cannot be verified.
We looked at this physician's review, the file, andMedicare rules. Based on this information, we decided that Medicare rules for coverage of a vertebral corpectomy and the insertion of an intervertebral biomechanical device have not been met.Therefore, we decided that the Plan does not have to pay fora vertebral corpectomy (63090) and the insertion of an intervertebral biomechanical device (22854) provided on March 16, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to providea pneumatic compression device (E0652).You asked the Plan to providea pneumatic compression device. You say that the enrollee has failed a basic pump.The Plan denied your request. The Plan says there are no post measurements over 4 weeks to support a good faith trial with the basic pump.The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required.We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided.Therefore, we decided that the Plan does not have to providea pneumatic compression device (E0652).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services providedon December 7, 2020 by a non-contracted provider.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 services were rendered by a non-contracted provider withoutprior 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 requested provider in this case is not a network provider with the Plan. The referring provider is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay forthe laboratory services provided on December 7, 2020 by a non-contracted provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services rendered on August 3, 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 was billed incorrectly.The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis code.We looked at the file and Medicare rules. The file shows that the claim was not billed with a valid primary diagnosis code.Therefore, we decided that the Plan does not have to pay forthe laboratory services rendered on August 3, 2020
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approveincontinence supplies.You asked the Plan to pre-approveincontinence supplies. You say that you need incontinence supplies beyond what you can get with the Plan's monthly over-the-counter benefit.The Plan denied your request. The Plan says this item is not a covered benefit.The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. While incontinence supplies may be appropriate in this case, Medicare does not offer coverage for these items.Therefore, we decided that the Plan does not have to pre-approveincontinence supplies.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea continuous glucose monitor (CGM).You asked the Plan to pre-approvethese services. You say that you disagree with the denial.The Plan denied your request. The Plan says you do not meet the criteria for coverage.The Plan must follow Medicare rules. Medicare rules say that a therapeutic CGM is covered when specific criteria are met.We looked at the file and Medicare rules. The file shows that you do not check your blood sugar levels four or more times per day. Based on this information, we decided that Medicarerules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pre-approvea continuous glucose monitor (CGM).