Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Sleep Safety bed.

You asked the Plan to pre-approve the bed. You say that this is medically necessary for the enrollee's disability. The Plan denied your request. The Plan says this is 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 the bed. Our reviewer says that the requested bed is not considered medically reasonable and necessary in this case. Our physician reviewer found Medicare does not pay for any items or services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. The request for the brand name Sleep Safety bed is not medically necessary as there is no indication that you require this brand of bed. The request appears to exceed your medical need and there is no evidence that this brand of bed is more effective or appropriate for your medical condition than an a non Sleep Safety bed.

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 bed have not been met. Therefore, we decided that the Plan does not have to pre-approve a Sleep Safety bed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a recliner and seat lift mechanism.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says there is no recent documentation of an inability to ambulate once standing.

The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions listed in the Medicare rules section are met.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found there are no objective imaging studies of x-rays taken of the hips to indicate the severity of the arthritis. There is no evidence of neuromuscular disease. The treating practitioner did not include the seat lift in the course of treatment. The seat lift is not likely to effect improvement in your condition. It is not likely to arrest or retard deterioration in your condition. The documentation does not show that you are completely incapable or standing from a chair in the home. The records show that you can ambulate.

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 a recliner and seat lift mechanism.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc-One (J7325).

You asked the Plan to pre-approve Synvisc-One. The Plan denied your request. The Plan says the information submitted does not meet the Plan's medical necessity guidelines for coverage.

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 Synvisc-One. Our reviewer says that Synvisc-One (J7325) is not medically reasonable and necessary for the enrollee. Our physician reviewer found the Plan requires a trial of Monovisc and/or Orthovisc before they will approve the requested drug. Our reviewer found that the enrollee has not tried and failed the required drug(s). Our physician reviewer also found that 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.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to the enrollee by an out-of-network provider on April 17, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.

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 services at issue in this appeal. The Plan did not pre-approve the services at issue. 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 the services provided to the enrollee by an out-of-network provider on April 17, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a manual wheelchair.

You asked the Plan to pre-approve manual wheelchair. You say that the enrollee needs a wheelchair due to
being a left leg below the knee amputee. The Plan denied your request. The Plan says the denial of
authorization for this item is correct, because the documentation does not show that the enrollee meets criteria
for a wheelchair.

The Plan follows Medicare rules. Medicare rules state that a manual wheelchair may be covered if certain
criteria are met.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve manual wheelchair. Our reviewer says
that the enrollee does not meet the criteria for the requested manual wheelchair.

Our physician reviewer found based on the medical records provided, there is no documentation that all of the required Medicare criteria for coverage of a manual wheelchair have been met.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of manual wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve a manual wheelchair.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve arthrodesis, posterior or posterolateral technique, single level; lumbar (with lateral transverse technique, when performed) (CPT code 22612), for the enrollee.

You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan denied your request. The Plan says research has not found it to be helpful for the enrollee's condition of for what is causing the enrollee's 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 service. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found dynamic flexion/extension x-rays demonstrating instability, reference to impending intra-operative instability and/or a psychosocial screen are not documented. (While the treating provider indicates 3 mm of anterolisthesis demonstrated on magnetic resonance imaging (MRI), the radiologist read does not evidence same. In addition, there is relative inconsistency regarding amount of mm of motion that is indicative of segmental instability.) The medical necessity has not been established at this time. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines. Therefore, the request for arthrodesis (fusion or join the lower or lumbar spine bones) at L4-5 is 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 service have not been met. Therefore, we decided that the Plan does not have to pre-approve arthrodesis, posterior or posterolateral technique, single level; lumbar (with lateral transverse technique, when performed) (CPT code 22612), for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for durable medical equipment provided on February 24, 2020,
by an OON provider.

You asked the Plan to pay for durable medical equipment. You say that you would like this claim reprocessed
and paid. The Plan denied your request. The Plan says prior authorization was not obtained by the member's
primary care physician. The Plan says that the referring provider is not in-network.

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 durable medical equipment provided on February
24, 2020, by an OON provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for cardiovascular genetic testing (81286, 81407, 81408, 81479) provided on September 14, 2020.

You asked the Plan to pay for cardiovascular genetic testing. You say that this was medically necessary. The Plan denied your request. The Plan says this is not covered.

The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular (CV) risk assessment panels, except the basic lipid panel, for symptomatic (with signs and symptoms) patients with suspected or documented CV disease because panel testing is not specific to a given patient's lipid abnormality or disease.

We looked at the file and Medicare rules. The services at issue are a CV risk assessment panel and are not covered. Based on this information, we decided that Medicare rules for coverage of cardiovascular genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for cardiovascular genetic testing (81286, 81407, 81408, 81479) provided on September 14, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the remote cardiovascular monitoring provided on November 25, 2020.

You asked the Plan to waive the coinsurance for the remote cardiovascular monitoring. You say that you were informed there would be a flat rate regardless of the monitor used. You say that you and Medicare are being over billed. The Plan denied your request. The Plan says the coinsurance applied correctly.

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 20% of the cost for Medicare-covered diagnostic procedures or tests.

You have been asked to pay $189.42, which is 20% of the allowed amount for the remote cardiovascular monitoring. The allowed amount is $947.12 (20% x $947.12 = $189.42). The remote cardiovascular monitoring falls within the "Outpatient diagnostic tests and therapeutic services and supplies" 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 coinsurance for the remote cardiovascular monitoring provided on November 25, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular risk assessment testing provided on June
3, 2020.

You asked the Plan to pay for the cardiovascular risk assessment testing. You say that you would like the plan
to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered
benefit.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed above, are not covered. Cardiovascular disease screening tests are only covered for certain
indications.

The laboratory services at issue in this appeal were requested solely for screening purposes. While Medicare
covers cardiovascular disease screening tests for certain indications, the documentation does not support that
the enrollee met criteria for the services rendered. Therefore, we decided that the Plan does not have to pay for
the cardiovascular risk assessment testing provided on June 3, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular risk assessment provided on September 21, 2020.

You asked the Plan to pay for the cardiovascular risk assessment. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says a treating provider did not orer these tests and the testing is not being used to manage or treat a specific medical problem or diagnosis.

The Plan must follow Medicare rules. Medicare rules say that all diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests must be ordered by the physician who is treating the beneficiary.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the cardiovascular risk assessment have not been met. Specifically, the record does not show that a treating physician ordered the billed testing services. Therefore, we decided that the Plan does not have to pay for the cardiovascular risk assessment provided on September 21, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the Transcatheter Mitral Valve Repair (TMVR) provided from September 13, 2020, to September 17, 2020.

You asked the Plan to pay for the TMVR. The Plan denied your request. The Plan says A valid clinical trial number was not billed on the claim.

The Plan must follow Medicare rules. Medicare rules say that it is mandatory to report a clinical trial number on claims for items/services provided in clinical trials/studies/registries, or under CED.

We looked at the file and Medicare rules. The claim was not submitted with a valid clinical trial number for the TMVR services. Based on this information, we decided that Medicare rules for coverage of the TMVR have not been met. Therefore, we decided that the Plan does not have to pay for the Transcatheter Mitral Valve Repair (TMVR) provided from September 13, 2020, to September 17, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM).

You asked the Plan to pre-approve therapeutic CGM. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of authorization for this device is correct, because the enrollee is not on at least 3 daily insulin injections and therefore does not meet coverage criteria.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results.

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of therapeutic CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM).
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 IRF care is medically necessary for the enrollee. The Plan denied your request. The Plan says the rules for IRF care have not been met and necessary care can be met at a lower level. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.

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 enrollee was admitted to an acute care hospital following a stroke.

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 diabetic supplies to test blood sugar two (2) times per
day.

You asked the Plan to pre-approve the supplies. You say that you need more test strips. The Plan denied your
request. The Plan says there is not enough evidence to support the need to test two (2) times a day.

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 supplies have not been met. Based on the information received,
there is not enough evidence to support the need to test 2 times a day. Your doctor would need to give
information why testing one (1) time per day is not acceptable. Therefore, we decided that the Plan does not
have to pre-approve diabetic supplies to test blood sugar two (2) times per day.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient hospital care.

You asked the Plan to pre-approve acute inpatient hospital care. You say that inpatient hospital care is
medically necessary. The Plan denied your request. The Plan says there is no documentation to support the
expectation that the enrollee will require a greater than 2 midnight stay in the hospital.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases,
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or
more.

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 acute inpatient hospital care. Our reviewer
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our
physician reviewer found the review indicates that the enrollee is a 79-year-old female with right shoulder pain
who is undergoing a planned right shoulder arthroplasty. The procedure is currently approved as an ambulatory
procedure. There is no documentation provided to support the expectation the enrollee will require a greater
than 2 midnight stay. The review has determined that the record does not show that at the time of inpatient
admission the admitting physician reasonably expected that the patient's necessary hospital care (including
earlier ED and/or observation care) would span two midnights.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the
Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion of interlaminar/interspinous process stabilization/distraction device, without fusion, including image guidance when performed, with open decompression, lumbar; single level (CPT code 22867), for the enrollee.

You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your request. The Plan says the services are 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 services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found detailed documentation is not evident regarding trial and failure of recent, reasonable and comprehensive less invasive conservative care measures for at least 6 months. Detailed documentation is also not evident regarding any objective exam findings to corroborate the subjective findings. Furthermore, there is limited published peer-reviewed literature that shows the request to be an effective and/or safe treatment for the noted pathology. Published studies do not demonstrate significant long-term health outcome advantage with the use of Coflex as an alternative to standard surgical treatment. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines. Therefore, the request for lumbar decompression at L4-5 with Coflex implant is 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve insertion of interlaminar/interspinous process stabilization/distraction device, without fusion, including image guidance when performed, with open decompression, lumbar; single level (CPT code 22867), for the enrollee.