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

We decided that the Plan does not have to pre-approve a lumbar interspinous decompression 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 this condition for over 10 years and it has greatly impacted her quality of life. The Plan denied your request. The Plan says there are not enough studies on the device to show it is safe and effective.
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 record indicates that the enrollee underwent laminectomy in
2020. The record indicates that the enrollee has multiple level disease for which operative treatment is
indicated. The record indicates the enrollee has advanced scoliosis, but no Cobb angle is recorded. 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 lumbar interspinous decompression device surgery
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation system (E2300).
You asked the Plan to pre-approve a power seat elevation system (E2300). You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says a power seat elevation system (E2300) is statutorily non-covered by Medicare and the Plan.
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. Medicare specifically excludes coverage of power seat elevation systems coded as E2300. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation system (E2300).
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 records provided support the need for IRF care. The Plan denied your request. The Plan says the guidelines for coverage of IRF care have not been met. The Plan says that the enrollee can safely receive the services needed in another setting.
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 confusion and a urinary tract infection. The enrollee's medical conditions 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. The enrollee does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that this 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bone growth stimulator (BGS).
You asked the Plan to pre-approve the BGS. You say that it is felt this is needed due to broken hardware which suggests non-healing. The Plan denied your request. The Plan says the criteria for use of this BGS are not met in the case.
The Plan must follow Medicare rules. Medicare rules say that a BGS may be covered for failed fusion of a joint when at least 9 months have passed since the last surgery.
In this case, the enrollee has joint surgery in March 2021. Since nine months have not passed, Medicare criteria for coverage of the BGS have not been met. Therefore, we decided that the Plan does not have to pre-approve a bone growth stimulator (BGS).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a multi-axial rotation unit.
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 item is miscoded.
The Plan must follow Medicare rules. The rules say that an axial rotation unit (L5982, L5984, L5985, L5986) is covered for beneficiaries whose functional level is 2 or above. We looked at the file and Medicare rules. The file shows that the requested axial unit requested under code L5986 is not covered because it is already included in the approved services. 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 multi-axial rotation unit.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a second opinion with an out of network (OON) tertiary level of care provider.

You asked the Plan to pre-approve the second opinion with an OON provider. You say that you have been to many in network cardiologists and that none of them have been able to determine the cause of your problems. You say that you are fearful for your life and want to go the requested OON provider because of their expertise. You say that the medical records provided support the need to be evaluated OON. The Plan denied your request. The Plan says there are in network cardiology providers who can evaluate and treat the enrollee's condition.

Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan providers available to meet enrollees' needs. Your contract with the Plan says that, with few exceptions, you must use contract providers for care. 

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 second opinion with an OON provider. Our reviewer says that the criteria for coverage of OON care have not been met. Our physician reviewer found although the enrollee has had a recent hospitalization for decompensated congestive heart failure (CHF), he has had a thorough ongoing evaluation of his heart failure with preserved ejection fraction. There is no documentation of cardiology visits since March 2021, and he was being appropriately followed in a specialized heart failure center with a thorough ongoing evaluation. Unfortunately, HFpEF is a difficult syndrome to treat, and exacerbations and hospitalizations can occur despite appropriate care. There does not appear to be any unique or unusual findings that would necessitate evaluation at an out of network hospital based on his current clinical condition and the Plan has appropriate facilities, technology and providers to manage his HFpEF in their specialized heart failure center where he was being followed previously. Referral to the out of network providers would not be considered medically necessary at this 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 second opinion with an OON provider have not been met. Therefore, we decided that the Plan does not have to pre-approve a second opinion with an out of network (OON) tertiary level of care provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Saxenda pen.
You asked the Plan to pre-approve a Saxenda pen. You say that this 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 a Saxenda pen.
Benefits for a Saxenda pen 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 admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve the SNF admission. You say that it is felt that SNF care would be beneficial
for you. The Plan denied your request. The Plan says you do not require skilled services on a daily basis.
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 SNF admission. Our reviewer says
that daily skilled services are not necessary. Our physician reviewer found the enrollee was treated in the
emergency department on 7/30/2021 after a fall causing back pain. Imaging showed only old compression
fractures and no new injuries. No neurological deficits were documented. The patient was stable after back pain
from a fall with no new medical problems, had no documented nursing needs. She was at high functional level
and does not need daily skilled therapies in an inpatient 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 SNF admission have not been met. Therefore, we decided that the Plan does
not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Volara System.

You asked the Plan to pre-approve a Volara System. You say that the individual modalities provided by the service have all been shown to be effective in airway clearance, secretion clearance, decreasing rates of infections, and preventing decline in lung function. The Plan denied your request. The Plan says medical studies have not proven that the requested 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 a Volara System. Our reviewer says that a Volara System is not considered medically reasonable and necessary in this case. Our physician reviewer found this system has 3 components: a nebulizer for inhaled medications, continuous positive end-expiratory pressure, and oscillating air flow. The system has not been shown to be clinically beneficial in the treatment of bronchiectasis, chronic cough, or MAC lung infection. There is no evidence the enrollee has tried and failed other airway clearance measures, including a flutter valve, nebulized normal saline, or manual percussion and postural drainage.

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 Volara System have not been met. Therefore, we decided that the Plan does not have to pre-approve a Volara System.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve the SNF services. You say that you have nowhere to go and will not be able to function without rehab. You say that the records provided support the need for SNF care. The Plan denied your request. The Plan says SNF care 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 the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there is no documentation that the patient requires skilled nursing services. There is evidence that the enrollee requires skilled therapy services, but not on a daily basis. The enrollee does not require the services needed on an inpatient basis, only in a SNF setting. Services in the home with home health care, or in a long-term care facility on a part-time basis appear appropriate 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 the SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Other
Decision: Favorable

We decided that the Plan has to pre-approve a second facet injection.
You asked the Plan to pre-approve the second facet injection. You say that the records provided support the need for the requested injections. The Plan denied your request. The Plan says that the criteria for coverage have not been met.
The Plan follows Medicare rules. Medicare rules say that a second facet injection is covered when the enrollee meets the criteria for the first diagnostic procedure and when there is a consistent positive response of at least 80% relief of primary pain. 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 second facet injection. Our reviewer says that the criteria for coverage have been met. Our physician reviewer found the enrollee has chronic neck and low back pain. She has tried physical therapy, a home exercise program and massage therapy. She had a successful epidural steroid injection and SI joint radiofrequency ablation (RFA). She had a first set of successful facet blocks with 100% relief of primary pain. 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 second facet injection have been met. Therefore, we decided that the Plan has to pre-approve a second facet injection.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the durable medical equipment provided November 17, 2020.
You asked the Plan to pay for the durable medical equipment. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says the reasonableness of the provided durable medical equipment is not established.
The Plan follows Medicare rules. Medicare rules say that a supplier may not contact an individual by telephone regarding the furnishing of a covered item except under specific circumstances. We looked at the file and Medicare rules. The Plan states that this item may have been ordered by an unsolicited outreach telephone call to the enrollee, and this request was not initiated by the enrollee or the enrollee's treating physician. The record does not show that written permission was obtained to make contact by telephone regarding the furnishing of this item. The record does not show that contact was initiated
regarding an item already furnished to the enrollee or another item furnished to the same enrollee within the past 15 months. Based on this information, we decided that Medicare rules for coverage of the durable medical equipment have not been met. Therefore, we decided that the Plan does not have to pay for the durable medical equipment provided November 17, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve colonoscopy services to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the OON colonoscopy services. You say that the colonoscopy services are medically necessary. The Plan denied your request. The Plan says there are network providers who can evaluate and treat the enrollee.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve colonoscopy 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 an Ossur Balance Knee.
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 requested services were incorrectly coded.
The Plan must follow Medicare rules. The rules say that L5925, L5930, L5845, L5848, L5850, L5856, L5857, L5858, L5859 are additional features and/or functions that do not describe a complete endoskeletal knee-shin system and must be used in combination with an L-code for a knee-shin system. We looked at the file and Medicare rules. The requested Ossur Balance Knee was requested with code L5845. This code is not appropriate, as the proper codes have already been approved. 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 an Ossur Balance Knee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve intravenous moderate (conscious) sedation/analgesia and therapeutic parenteral drug services to be provided during dental treatment.
You asked the Plan to pre-approve the intravenous moderate sedation/analgesia and therapeutic parenteral drug services. You say that the requested services are medically appropriate. You say that you do not have the money to pay for the sedation needed during oral surgery. You say that all of your teeth are being removed. You say that you are in pain and cannot eat, sleep, or function normally. The Plan denied your request. The Plan says the services in dispute are non-covered under Medicare and under your Plan contract.
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 intravenous moderate (conscious) sedation/analgesia and therapeutic parenteral drug services to be provided during dental treatment
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Freestyle Libre, continuous glucose monitor (95250).
You asked the Plan to pre-approve the Freestyle Libre. You say that you disagree with the denial for the Freestyle Libre and you would like to request an appeal. The Plan denied your request. The Plan says the coverage criteria for the Freestyle Libre has not been met.
The Plan follows Medicare rules. Medicare rules say that therapeutic CGMs may be considered reasonable and necessary for enrollees with diabetes who meet the criteria referenced 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 the Freestyle Libre. Our reviewer says that the Medicare criteria for a continuous glucose monitor were not met. Our physician reviewer found in this case the record indicates that the enrollee has diabetes. The enrollee is not on insulin and does not check his blood sugar four or more times a day. The elements of the coverage criteria are not satisfied, and 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 Freestyle Libre have not been met. Therefore, we decided that the Plan does not have to pre-approve Freestyle Libre, continuous glucose monitor (95250).