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

We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) scan of the brain (70553).
You asked the Plan to pre-approve an MRI scan of the brain. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve an MRI scan of the brain. Our reviewer says that the services are not medically necessary. Our physician reviewer found the physical exam conducted on this enrollee was not detailed and the history of parasthesias is insufficient to provide an indication for MRI. According to the notes a neurology consult is planned but not yet completed. The medical necessity for an MRI of the brain should be determined by a specialist in neurology. 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 MRI scan of the brain have not been met. Therefore, we decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) scan of the brain (70553).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex Superion spacer.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has lumbar spinal stenosis. The requested Vertiflex Superion spacer is considered experimental/investigational in nature, as more research is needed to show safety and efficacy. The services are therefore not reasonable or medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex Superion spacer.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the remaining 10 Hyperbaric Oxygen Therapy sessions.
You asked the Plan to pre-approve 40 Hyperbaric Oxygen (HBO) therapy sessions. You say that without HBO the enrollee is at very high risk of losing the leg or death if amputation is needed. The Plan denied your request. The Plan says 30 visits are approved initially and then you will need to submit further information about the wound and how it is healing.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.
We looked at the file and Medicare rules. The enrollee must be evaluated after 30 days before more sessions can be approved. Based on this information, we decided that Medicare rules for coverage of the remaining 10 Hyperbaric Oxygen (HBO) therapy sessions have not been met. Therefore, we decided that the Plan does not have to pre-approve 10 additional Hyperbaric Oxygen Therapy sessions.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the knee scooter, crutch substitute, lower leg platform, with or without wheels (E0118).
You asked the Plan to pre-approve the knee scooter. You say that you want to file an appeal for the denial of a knee scooter. The Plan denied your request. The Plan says this item is considered a comfort/convenience item and not covered.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve the knee scooter, crutch substitute, lower leg platform, with or without wheels (E0118).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable ventilator.
You asked the Plan to pre-approve a portable ventilator. You say that the requested portable ventilator is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested portable ventilator.
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. 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 ventilator. Our reviewer says that the enrollee does not meet criteria for the requested portable ventilator. Our physician reviewer found the system is not medically necessary. This system is not a true ventilator. It is a portable device that delivers oxygen under positive pressure via nasal pillows, meant to be used during activity. It does not have the capabilities of a ventilator. There is no convincing evidence that this device is beneficial in the treatment of COPD. 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 ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a portable ventilator.
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 you need IRF care. 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 are a 61-year-old woman with a history of obesity, multiple surgeries for hiatal hernia, chronic abdominal pain, and chronic anemia.
In this case, the documentation does not support that the complexity of your nursing, medical and rehabilitation
needs require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The
documentation does not support that you require at least 3 hours a day/5 days a week, or 15 hours over 7
consecutive days, of therapy 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 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 an osteogenesis stimulator.
You asked the Plan to pre-approve the stimulator. You say that this is medically necessary. The Plan denied
your request. The Plan says there is not yet a complete osseous union.
The Plan must follow Medicare rules. The rules say that an electrical bone stimulator is covered for nonunion
of long bone fractures. Nonunion of long bone fractures is considered to exist only when serial radiographs
have confirmed that fracture healing has ceased for 3 or more months prior to starting treatment with the
electrical bone growth stimulator. Serial radiographs must include a minimum of 2 sets of radiographs
separated by a minimum of 90 days.
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 stimulator.
Our reviewer says that the requested services are not medically reasonable or necessary. Our physician
reviewer found that in this case, the record indicates that the enrollee had a femur fracture in September 2020
treated with open reduction internal fixation. A note on February 11, 2021 indicates that the fracture is "pretty
much healed." This is supported by the x-ray from January 2021. A CT scan in March 2021 however showed
minimal callus and there was also concern for loosening of the knee prosthesis. No further records were
provided. Only one set of x-rays have been submitted that support possible nonunion. The elements of the
coverage rule are not satisfied.
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 stimulator have not been met. Therefore, we decided that the Plan does not
have to pre-approve an osteogenesis stimulator.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Zgeva (J0897).
You asked the Plan to pre-approve Zgeva (J0897). You say that you want the enrollee to be treated with this drug. The Plan denied your request. The Plan says the enrollee has not first tried and failed pamidronate or zoledronic acid.
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 Zgeva (J0897). Our reviewer says that
the drug is not medically reasonable and necessary. Our physician reviewer found the patient has not tried and
failed the required drug(s). There is no documentation provided indicating that the Plan's required drug(s)
would likely be less effective and/or likely have adverse effects 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 Zgeva (J0897) have not been met. Therefore, we decided that the Plan does not
have to pre-approve Zgeva (J0897).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on December 21, 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 services rendered by non-participating providers require 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 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 laboratory services provided to the enrollee on December 21, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device. You asked the Plan to pre-approve the Vertiflex device. You say that this device is medically necessary. The Plan denied your request. The Plan says this device is not covered by Medicare. The Plan must follow Medicare rules. Medicare rules say experimental devices are not covered by Medicare. 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 Vertiflex device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental. More research is needed to show safety and efficacy. 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 Vertiflex device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the total electric hospital bed (E0265).
You asked the Plan to pre-approve the total electric hospital bed. You say that you've been to the emergency room multiple times due to falling. This hospital bed is needed for safety of getting in and out of bed. The Plan denied your request. The Plan says this item is not covered.
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 the total electric hospital bed (E0265).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the intravenous infusion, hydration; initial, 31 minutes to 1 hour (96360) and the intravenous infusion, hydration; each additional hour (96361) provided on October 13, 2020. You asked the Plan to waive the coinsurance. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the coinsurance has been applied correctly to the services provided. The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for all other Medicare covered Part B drugs. You have been asked to pay $53.75 ($268.77 x 20% coinsurance) for the Medicare Part B drug infusions provided. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the intravenous infusion, hydration; initial, 31 minutes to 1 hour (96360) and the intravenous infusion, hydration; each additional hour (96361) provided on October 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the MyoPro Motion G device, custom myoelectric upper extremity orthosis (L8702).
You asked the Plan to pre-approve the orthotic device. You say that given that traditional OT strategies have been tried and failed, her attending provider is recommending the enrollee for myoelectric orthotic restoration. The Plan denied your request. The Plan says this item is considered experimental and investigational. Enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The rules also say that experimental and investigational devices are not covered. Medicare rules also say that plans can require enrollees to get care from 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 looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the orthotic device have not been met. Therefore, we decided that the Plan does not have to pre-approve the MyoPro Motion G device, custom myoelectric upper extremity orthosis (L8702).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for practitioner services provide to the enrollee on November 5, 2020 and billed under code 99100.
You asked the Plan to pay for this service. You believe this claim should be paid by the Plan. The Plan denied your request. The Plan says this claim denied due to an issue with the taxonomy code. The Plan states that code 99100 is listed as 'Status B" in the Medicare Physician Fee Schedule Database, which means that payment for this service is always included in payment for other services performed on the same date that are paid under the Medicare Physician Fee Schedule. The Plan has reprocessed and will pay code 00142, however the Plan will uphold CPT 99100 as bundled into payment for code 00142.
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 code 99100 cannot be paid separately due to its bundled relationship with code 00142. Therefore, the Plan does not have to pay for practitioner services provide to the enrollee on November 5, 2020 and billed under code 99100.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an air purifier.
You asked the Plan to pre-approve an air purifier. You say that you believe the air in your home is toxic. The Plan denied your request. The Plan says an air purifier is not medical in nature.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve an air purifier.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa.
You asked the Plan to pre-approve Euflexxa. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that viscosupplementation therapy for the knee via intraarticular
injections of hyaluronic preparations will be considered medically reasonable and necessary when
specific 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 Euflexxa. Our reviewer says that the
services are not medically necessary. Our physician reviewer found there is no documentation indicating the
enrollee has failed at least three months of conservative therapy such as anti-inflammatory medications and
physical therapy or previous steroid injections. The review has determined that the enrollee does not meet the
coverage 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 Euflexxa have not been met. Therefore, we decided that the Plan does not have
to pre-approve Euflexxa.
Appeal type: Outpatient Therapies
Decision: Favorable

We decided that the Plan has to pre-approve intradialytic parenteral nutrition therapy.

You asked the Plan to pre-approve parenteral nutrition therapy. You say that you have formulated a patient-specific formula to meet the enrollee's needs for end-stage renal disease with malnutrition. The Plan denied your request. The Plan says that the denial of authorization for this service is correct, because the records do not support that the enrollee meets the Medicare coverage criteria.

The Plan follows Medicare rules. Medicare rules state that enteral and parenteral nutritional therapy may be covered under certain circumstances. 

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 parenteral nutrition therapy. Our reviewer says that the enrollee meets the Medicare criteria for the requested nutrition therapy. Our physician reviewer found the enrollee has end-stage renal disease on hemodialysis. Intradialytic parenteral nutrition had been requested due to malnutrition and inadequate protein intake. The enrollee meets the criteria for malnutrition and attempts to counsel and increase dietary protein intake have failed. Intradialytic parenteral nutrition is medically indicated in this case and represents reasonable medical intervention and therapy. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of parenteral nutrition therapy have been met. Therefore, we decided that the Plan has to pre-approve intradialytic parenteral nutrition therapy.

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 to open the case again, we will send you a letter.