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

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.

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 enrollee is receiving the appropriate care in the Inpatient Rehabilitation Facility.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for 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 skilled nursing facility (SNF) services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genicular nerve blocks.

You asked the Plan to pre-approve the requested services. You say that the enrollee has failed conservative measures. The Plan denied your request. The Plan says the requested services are considered investigational for the treatment of chronic knee pain.

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 requested services. Our physician reviewer found that the enrollee has osteoarthritis of the right knee. She has tried Acetaminophen, physical therapy, and a home exercise program. She has had intra-articular steroid injections with sustained benefit. The requested genicular nerve block is considered an experimental/ investigational procedure at this time. Therefore, the request is deemed not medically reasonable or necessary. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve genicular nerve blocks.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services provided from September 10, 2020, through October 18, 2020.

You asked the Plan to pay for the psychotherapy services. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they approved in advance.

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 did not pre-approve the psychotherapy services. 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 psychotherapy services provided from September 10, 2020, through October 18, 2020.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve MRI of the brain for the enrollee.

You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your request. The Plan says that the requested procedure is not standard of care for the enrollee's condition.

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 the MRI. Our reviewer says that the requested MRI is medically reasonable and necessary. Our physician reviewer found in this case, the enrollee has a history of a neoplasm that had been resected. It would otherwise be reasonable and necessary to continue surveillance imaging at this time to evaluate for tumor/adenoma recurrence. In as much this service can be considered to be reasonable and necessary and therefore eligible for coverage. 

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 MRI have been met. Therefore, we decided that the Plan has to pre-approve MRI of the brain for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve implantation of the Coflex device.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says this procedure appears to be experimental, as there is evidence that there are increased harms associated with implantation of this device.

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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Coflex device is experimental. More research is needed to show the safety and efficacy of the Coflex device. It is not the best surgical option in this case. Coflex is not medically needed. 

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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve implantation of the Coflex device.
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 this is medically necessary. The Plan denied your request. The Plan says the enrollee's needs could be met at 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 above. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient's medical status does not require intensive physician or nursing supervision in an IRF. While the patient may benefit from and participate in multiple therapies, the patient's functional level does not require this therapy on an 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.

You asked the Plan to pre-approve foot orthotics. You say that this is medically necessary. The Plan denied your request. The Plan says this item is not a covered benefit.

Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. 

Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Chantix (J8499).

You asked the Plan to pre-approve Chantix. You say that the enrollee has tried and failed over the counter patches and lozenges. The Plan denied your request. The Plan says the requested drug is considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the requested drug is not covered under Medicare Part B.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered 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 Chantix (J8499).

Benefits for Chantix 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) care beyond February 26, 2021.

You asked the Plan to pre-approve continued SNF care. You say that that this is medically necessary. The Plan denied your request. The Plan says the enrollee's needs are now custodial.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve continued SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that from a nursing perspective, the enrollee received oral medications. The enrollee had stable vital signs. She had right knee pain and was treated for a urinary tract infection. Regarding rehabilitation services, the enrollee received physical and occupational therapy in the SNF. By the dates in question, the enrollee was dependent for functional mobility and remained non-ambulatory. She required varying assist with activities of daily living. There are no identifiable skilled nursing or therapy service needs. The enrollee 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 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 February 26, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance angiography of the head (70544).

You asked the Plan to pre-approve the MRI. You say that that the medical records provided will show proof of
medical necessity. The Plan denied your request. The Plan says the records do not support that the requested
service is medically necessary.

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 the MRI. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found the telemedicine visit of 1/21/21 does not include a detailed neurological examination. This
enrollee has no know history of suspected vasculitis, cerebral aneurysm or other disease requiring MRA
evaluation of the brain (CPT 70544) nor does she have a history of malignancy or signs of infection to require
MRI of the brain without and with IV contrast injection (CPT 70559). The enrollee does however have
significant confusion and at age 79 would qualify for MRI of the brain without contrast (CPT 70557) however
that was not the exam requested. If the order is changed to the appropriate study of CPT 70557 MRI of the
brain without contrast the exam should be approved at that time.

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 MRI have not been met. Therefore, we decided that the Plan does not have
to pre-approve magnetic resonance angiography of the head (70544).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a total electric hospital bed (E0265).

You asked the Plan to pre-approve this item. You say that a total electric hospital bed is medically necessary for the enrollee. The Plan denied your request. The Plan says a total electric hospital bed is not a covered benefit under the enrollee's contractual policy or 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 for the enrollee 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 (E0265).
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve a repeat radiofrequency ablation (RFA) injection for the enrollee.

You asked the Plan to pre-approve the RFA. You say that this is medically necessary. The Plan denied your request. The Plan says that the clinical information shows the presence of non-facet pathology.

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 RFA. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee had radiofrequency ablation of the medial branch blocks before, and achieved excellent relief for greater than six months. The pain has returned, so the request is again 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 RFA have been met. Therefore, we decided that the Plan has to pre-approve a repeat radiofrequency ablation (RFA) injection for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6530.

You asked the Plan to pre-approve the compression stockings. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered product.

The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are noncovered because they do not meet the statutory definition of a surgical dressing. 

Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6530.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ondansetron.

You asked the Plan to pre-approve Ondansetron. You say that this medication has benefited the enrollee and is medically necessary. The Plan denied your request. The Plan says coverage of this medication is the responsibility of the enrollee's prescription drug plan.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered 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 Ondansetron.

Benefits for Ondansetron 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: 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 above. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. In addition, the patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. Finally, there is not a reasonable expectation that this patient 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy services to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve OON services. The Plan denied your request. The Plan says there are participating providers in your network who are able to evaluate you.

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 physical therapy services at issue in this appeal. We found no exception that would require the Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve physical therapy services to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the removable foot inserts (L3020).

You asked the Plan to pre-approve foot orthotics. You say that you are pre-diabetic and your doctor is advising you that you need to walk in order to prevent diabetes. You are unable to walk without the inserts because of being in a great deal of pain. The Plan denied your request. The Plan says this item is not a covered benefit.

Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. 

Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve the removable foot inserts (L3020).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Superion Interspinous Spacer procedure.

You asked the Plan to pre-approve Insertion of interlaminar/interspinous process stabilization/distraction
device, without open decompression or fusion, including image guidance when performed, lumbar; single level
(22869) and Insertion of interlaminar/interspinous process stabilization/distraction device, without open
decompression or fusion, including image guidance when performed, lumbar; second level (List separately in
addition to code for primary procedure) (22870). You say that the enrollee has chronic pain and needs this
procedure. The Plan denied your request. The Plan says a review of the current medical literature indicates that
this service is considered experimental and investigational.

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 Insertion of interlaminar/interspinous
process stabilization/distraction device, without open decompression or fusion, including image guidance when
performed, lumbar; single level (22869) and Insertion of interlaminar/interspinous process
stabilization/distraction device, without open decompression or fusion, including image guidance when
performed, lumbar; second level (List separately in addition to code for primary procedure) (22870). Our
reviewer says that the requested items/services are not considered medically reasonable and necessary in this
case. Our physician reviewer found the spacer device is 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 Insertion of interlaminar/interspinous process stabilization/distraction device,
without open decompression or fusion, including image guidance when performed, lumbar; single level
(22869) and Insertion of interlaminar/interspinous process stabilization/distraction device, without open
decompression or fusion, including image guidance when performed, lumbar; second level (List separately in
addition to code for primary procedure) (22870) have not been met. Therefore, we decided that the Plan does
not have to pre-approve the Superion Interspinous Spacer procedure.