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

We decided that the Plan does not have to pre-approve a spinal distraction device surgery.
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 suffered from lumbar spinal stenosis for over 5 years and it has greatly impacted her quality of life. The Plan denied your request. The Plan says Medical studies haven't proven that the device is helpful for treatment of the enrollee's health problem.
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 in this case, the enrollee indicates that the enrollee has chronic low back
pain and radiculopathy. The record does not contain the results of imaging studies demonstrating moderate
spinal stenosis. The elements of the coverage criteria are not satisfied. The requested service cannot be
recommended.
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 a spinal distraction device surgery.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a replacement socket (CPT code L5964).
You asked the Plan to pre-approve the socket. You say that you are requesting review of denial of services. The Plan denied your request. The Plan says protection of the prosthesis can be achieved with the custom shaped protective cover above knee (CPT code L5705), and that has been approved. The Plan states the cover you are requesting CPT code is not medically necessary and cannot be covered. The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the socket have not been met. There is no documentation that supports that your activity subjects you to harsh environmental situations or that you engage in any extraordinary activities that would justify the need for extra protection with a flexible outer surface covering system (L5964). No justification is given in the clinical documentation for request for extra protection with a flexible outer surface covering system (L5964). Therefore, we decided that the Plan does not have to pre-approve a replacement socket (CPT code L5964).
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on January 16, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says this provider is not enrolled in the Medicare Program.

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 January 16, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.

You asked the Plan to pre-approve the LTACH services. You say that the enrollee will need 3-4 weeks to continue weaning off oxygen. The Plan denied your request. The Plan says the stay is not medically necessary.

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 the enrollee appears to be gradually improving but needs additional short-term acute care services which can be safely provided at the current acute care facility for the time being. The enrollee does not require services at the LTACH that are not already available at the current facility. There are no services at the LTACH that the enrollee requires that are not already available and covered at the current facility. Therefore, this request for LTACH services will be considered not medically necessary as there is no advantage to transfer at this time. Transfer to a lower level of care may be considered when treatment has completed.

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 LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an eye exam provided on
February 26, 2021.
You asked the Plan to waive the copayment the eye exam. The Plan denied your request. The Plan says he claim processed appropriately according to the billing by the provider for the services rendered and the structure of your benefit plan.
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 $10 copayment for Vision Care. You have been asked to pay a $10 copayment for the eye exam. The eye exam falls within the Vision Care benefit category. 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 copayment for an eye exam provided on February 26, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.

You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not qualify for SNF coverage. You do not have documented skilled nursing needs. You do not have documented skilled therapy needs. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of your condition. Your care needs at this point are custodial and, as a practical matter, can be provided at a lower level of care.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not qualify for SNF coverage. You do not have documented skilled nursing needs. You do not have documented skilled therapy needs. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of your condition. Your care needs at this point are custodial and, as a practical matter, can be provided at a lower level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
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 the patient appears to be more stable and only requires short-term additional acute care services which can safely be administered at the current acute care facility for the time being. The patient does not require services at the LTACH that are not already available at the current facility. There are no services at the LTACH that the patient requires that are not already available and covered at the current facility. Therefore, this request for LTACH services will be considered not medically necessary at this time as there is no advantage to transfer. Transfer to a lower level of care may be considered at a later date when treatment has completed.
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 LTACH 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 this is medically necessary. The Plan
denied your request. The Plan says the enrollee can continue treatment at the current hospital.
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 the documentation does not support that the enrollee requires services at the LTACH
that are not available at the acute care hospital where he is currently receiving care.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hyalgan/Supartz injection (CPT code J7321).
You asked the Plan to pre-approve the injection. You say that this is being requested so you can walk. You state you cannot bend your legs. The Plan denied your request. The Plan says the documentation provided did not indicate that you had tried and failed three (3) months of conservative treatment, have not had previous joint aspirations or corticosteroid injections, thus not meeting the clinical criteria to have the Hyalgan/Supartz Injection.
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 injection. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found there is no documentation of physical therapy, prior knee aspiration or injection with steroid.
Therefore, the request does not meet criteria and the request is considered 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 injection have not been met. Therefore, we decided that the Plan does not
have to pre-approve Hyalgan/Supartz injection (CPT code J7321).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for a family pool membership provided on
January 5, 2019.
You asked the Plan to reimburse you for a family pool membership. The Plan denied your request. The Plan says the recreation center is not a qualified health club or fitness facility.
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers gym benefits only when provided by a qualified health club or fitness facility. The Plan's rules for coverage of gym benefits have not been met because the family pool membership was not provided by a qualified health club or fitness facility per the Plan's benefit. Therefore, we decided that the Plan does not have to reimburse you for a family pool membership provided on January 5, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.

You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.

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 the enrollee was admitted following a ventricular tachycardia induced cardiac arrest. The enrollee has anoxic brain injury. The enrollee is still on a ventilator and unable to be weaned due to anoxic brain injury. The enrollee continues to receive acute care services, and these have not been denied. The medical record does not indicate that the enrollee requires services that they are not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules are not satisfied. The requested service cannot be recommended. 

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 LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the MyoPro Motion G Orthotic device (Current Procedural Terminology (CPT) code L8702), for the enrollee.

You asked the Plan to pre-approve the device. You say that the enrollee needs the orthosis since they need the support for their weak arm and restoration of the arm function to improve their independence at home for activities of daily living. The Plan denied your request. The Plan says the device 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 the device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the record indicates that the enrollee had a stroke in 2015 and has left arm weakness and spasticity without contracture. The records submitted from the ordering physician are insufficient to support the medical necessity and reasonableness, as defined by Medicare rules, of the requested service in the enrollee's specific clinical scenario. The elements of the coverage criteria are not satisfied. The requested service cannot be recommended.

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 MyoPro Motion G Orthotic device (Current Procedural Terminology (CPT) code L8702), for the enrollee.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve the Barostim Neo System Implant (CPT code(s): 0266T and C1825), for the enrollee.
You asked the Plan to pre-approve the services. You say that the enrollee suffers from dyspnea on exertion, shortness of breath, orthopnea, and fatigue. The Plan denied your request. The Plan says that the services are considered experimental and investigational.
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 services. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee in question has all the FDA approved indications for the use of this device including current Class II and recent Class III symptoms, is on maximally tolerated guideline directed therapy with good BP and pulse control, and has an EF of 35% or less (2). In carefully selected circumstances, Barostim Neo may have a limited role in enrollees who have significant recurrent symptoms and signs of significant CHF despite full guideline directed therapy with randomized published data and specific FDA indications for its use which are met in this situation. The enrollee would therefore meet medical necessity and reasonableness criteria of the applicable CMS Section 1862(a) 1 (A) rule for the use of Barostim in this clinical situation. 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 been met. Therefore, we decided that the Plan has to pre-approve the Barostim Neo System Implant (CPT code(s): 0266T and C1825), for the enrollee.
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.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on November 2, 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 if a laboratory assays two or more genes in a patient in parallel, then those two or more genes will be considered part of the same panel.

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 pay for the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the denial remains upheld as non-covered as Medicare denies coverage when a laboratory assays two or moregenes in a patient in parallel. Those two or more genes will be considered part of the same panel.

A panel constitutes a single procedural service, so one CPT code must be submitted for the panel. Medicare non-coverage applies to both contracted and non-contracted providers and cannot be overridden by plan directed care. The review has determined that the services at issue in this case 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 services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services provided to the enrollee on November 2, 2020.