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

We decided that the Plan does not have to pre-approve Freestyle Libre System sensors (E1399).
You asked the Plan to pre-approve Freestyle Libre System sensors. You say that the items are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that 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 Freestyle Libre System sensors. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the plan requires that the enrollee be on 3 shots of insulin per day and check blood glucose (BG) 4 times per day and adjust insulin doses according to BG level. None of these are present in this case nor is it explained why it is important for the enrollee to know his BG level multiple times per day since they do not take medications that cause low BG. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Freestyle Libre System sensors have not been met. Therefore, we decided that the Plan does not have to pre-approve Freestyle Libre System sensors (E1399).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not have to pre-approveadmission to an inpatient rehabilitation facility (IRF).You asked the Planto pre-approveIRF care. You say that this is medically necessary.The Plandenied your request. The Plansaysthere is no evidence that the member's minimal therapy needs are goals which can only be achieved by the medical support of an interdisciplinary team.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 you are medically stable with no evidence of need for supervision by a PMR physician. There is no need for acute rehab nursing care. You may benefit from PT and OT, but you do not require an intensive program. This is not medically necessary based on your current functional status and medical stability.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 Plandoes not haveto pre-approveadmission to an inpatient rehabilitation facility (IRF).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve electrical bone growth stimulator (E0747).
You asked the Plan to pre-approve electrical bone growth stimulator. You say that the records should support the necessity of the service in dispute. The Plan denied your request. The Plan says these services are not reasonable and necessary.
The Plan must follow Medicare rules. The rules say that an electrical bone stimulator is covered for nonunion of long bone fractures. Nonunion of long bone fractures is considered to exist only when serial radiographs have confirmed that fracture healing has ceased for 3 or more months prior to starting treatment with the electrical bone growth stimulator. Serial radiographs must include a minimum of 2 sets of radiographs separated by a minimum of 90 days. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve electrical bone growth stimulator. Our reviewer says that the enrollee does not meet Medicare criteria. Our physician reviewer found that not enough time has passed to establish the diagnosis of foot fracture nonunion. Therefore, the criteria was not 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 electrical bone growth stimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve electrical bone growth stimulator (E0747).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve four additional occupational therapy home health visits.
You asked the Plan to pre-approve the additional visits. You say that this is medically necessary. The Plan denied your request. The Plan says you are independent with activities of daily living, and there is no longer a skilled need for occupational therapy.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 additional visits. Our reviewer says that the requested additional visits are not medically reasonable or necessary. Our physician reviewer found four additional skilled occupational therapy services are not required to effectively provide treatment, care, and/or services which are medically necessary for you. You are independent in ADLs and toilet hygiene. Your range of motion deficits can be addressed with an independent home exercise program. Your functional status does not require the 4 additional skilled OT visits for your condition. 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 additional visits have not been met. Therefore, we decided that the Plan does not have to pre-approve four additional occupational therapy home health visits.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve routine transportation.You asked the Plan to pre-approve routine transportation. The Plan denied your request. The Plan says that neither Medicare nor the health plan covers routine transportation.The Plan must follow Medicare rules. Medicare does not cover transport in a vehicle that is not an ambulance. The Plan follows the same rule. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Medicare rules for coverage of routine transportation have not been met.Therefore, we decided that the Plan does not have to pre-approve routine transportation.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out of network (OON) provider.You asked the Plan to pre-approvecolonoscopy. You say that this enrollee has been seen by your provider in the past and it would impact the enrollee's care if you are unable to treat them.The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this provider is out-of-network with the Plan and the enrollee can be treated by an in-network gastroenterology specialist.Medicare rules say that plans can require enrollees to get care from networkproviders. 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. No continuity of care issue has been identified in this case. 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-approvethe medical services to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve trial of a spinal cord stimulator (SCS).
You asked the Plan to pre-approve the SCS trial. You say that it is felt that this is necessary to treat the enrollee's pain. The Plan denied your request. The Plan says there is no documentation showing arachnoiditis, nerve root injuries, and complex regional pain syndrome. Therefore, this cannot be covered.
The Plan follows Medicare rules. Medicare rules say that SCS placement may be covered when the enrollee meets the criteria listed 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 SCS trial. Our reviewer says that the requested SCS is not considered reasonable and necessary based on the LCD rules. Our physician reviewer found this 69-year-old man has chronic low back pain. He has had epidural steroid injections, Physical Therapy and a HEP. He is currently taking Norco and Tizanidine for pain. His physical exam documents none of the Budapest criteria for complex regional pain syndrome. He has not had prior spine surgery or arachnoiditis. He does not have any evidence-based indication for this procedure.
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 SCS trial have not been met. Therefore, we decided that the Plan does not have to pre-approve trial of a spinal cord stimulator (SCS).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approve Fulphia.You asked the Planto pre-approvethe drug. You say that this is medically necessary.The Plandenied your request. The Plansaysthis is not medically necessary.The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found the NCCN Guidelines Version 2.2020 Management of Neutropenia, pages MGF-1, 2, MGF-A 1and 2 of 5, do not list the planned chemotherapy combination as high risk (>20%) or intermediate risk (10-20%) Although patient factors, such as age can be used to determine use for intermediate risk regimens, there is no recommendation to use patient risk factors to determine use of growth factors, such as Fulphil, for low risk regimens. Therefore, the documentation does not support that the Fulphia is medically reasonable and necessary for the enrollee. The documentation does not support that the drug is safe and effective for the enrollee.Welooked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the drug have not been met.Therefore, we decided that the Plandoes not haveto pre-approveFulphia.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit and physician services to be provided by an out of network (OON) provider.You asked the Plan to pre-approve an office visit and physician services. You say that you would like approval for these services.The Plan denied your request. The Plan says there are in-network providers available for these services.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 an office visit and physician services to be provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve wig, any type (A9282).You asked the Plan to pre-approvethe wig. You say that youare experiencing hair loss due to an immune disorder and you are requesting coverage for a wig due to the alopecia.The Plan denied your request. The Plan says this item is not covered.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured.Therefore, we decided that the Plan does not have to pre-approvewig, any type (A9282).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the bone surgery on tooth numbers UA and LA (D7471).You asked the Plan to pre-approve the bone surgery on tooth numbers UA and LA (D7471). You say that this procedure is necessary for you to be able to wear your dentures which you need in order to be able to eat. The Plan denied your request. The Plan says the services are not covered benefits.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 bone surgery on tooth numbers UA and LA (D7471) are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the bone surgery on tooth numbers UA and LA (D7471)
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hypoglossal nerve stimulation.You asked the Plan to pre-approve these services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are not covered.The Plan must follow Medicare rules. The rules say that procedure code 0466T is considered not medically necessary.We looked at the file and Medicare rules. The services at issue are hypoglossal nerve stimulation described by procedure code 0466T. This code is denied by Medicare as not medically necessary.Therefore, we decided that the Plan does not have to pre-approve hypoglossal nerve stimulation.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital services rendered to the enrollee from June 30, 2019 to July 2, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were unauthorized post-stabilization.
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, approval is required.
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 these services. Our reviewer says that the enrollee was stable for transfer to a network facility. Our physician reviewer found the enrollee arrived to the emergency department (ED) following a witnessed cardiac arrest. He was alert and following commands in the ED. The enrollee was hemodynamically stable and chest pain is determined to be musculoskeletal in nature. All lab test results, and diagnostic imaging has confirmed that the enrollee's emergency cardiac condition had stabilized. The post-stabilization services were not reasonable or medically necessary. The treating physician did not document (in the physician notes, on a form, or in an order) that the enrollee was not stable for transfer on any dates of service. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the inpatient hospital services rendered to the enrollee from June 30, 2019 to July 2, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Insertion of Interlaminar/Interspinous Process Stabilization/Distraction Device, lumbar single level and Insertion of Interlaminar/Interspinous Process Stabilization/Distraction Device, lumbar second level.You asked the Plan to pre-approveInsertion of Interlaminar/Interspinous Process (22869) and Insertion of Interlaminar/Interspinous Process (22870). You say that this is the most appropriate treatment for the enrollee.The Plandenied your request. The Plan says this procedure is not reasonable and necessary under Medicare guidelines.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 (22869) and Insertion of Interlaminar/Interspinous Process (22870). Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the device remains experimental. More research is needed to show safety and efficacy.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Insertion of Interlaminar/Interspinous Process (22869) and Insertion of Interlaminar/Interspinous Process (22870) have not been met.Therefore, we decided that the Plan does not have to pre-approveInsertion of Interlaminar/Interspinous Process Stabilization/Distraction Device, lumbar single level and Insertion of Interlaminar/Interspinous Process Stabilization/Distraction Device, lumbar second level.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the incision and drainage of an abscess (10061) provided on June 22, 2019.
You asked the Plan to pay for the incision and drainage of an abscess. You say that this should be paid. The Plan denied your request. The Plan says there is a more appropriate code for the service performed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 10061 is incision and drainage of abscess (eg, carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); complicated or multiple. 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 incision and drainage of an abscess. Our reviewer says that CPT code 10061 is not supported by the records. Our physician reviewer found the medical records provided does not include documentation to corroborate that an Incision and drainage of abscess (eg, carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); complicated or multiple was performed on June 22, 2019, therefore the service cannot be validated and is not eligible for reimbursement consideration. 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 incision and drainage of an abscess have not been met. Therefore, we decided that the Plan does not have to pay for the incision and drainage of an abscess (10061) provided on June 22, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveadmission to a skilled nursing facility (SNF).You asked the Plan to pre-approvethe SNF admission. You say that you feel that you need care in the SNF setting.The Plan denied your request. The Plan says the care you require is custodial in nature. You do not need daily care from a skilled nurse or therapist.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 the SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the beneficiary is a 73 year old female admitted to the hospital for an elective biopsy and thermal ablation of a known renal mass. She has had lethargy and pain during the postoperative period. From a nursing perspective, the beneficiary received oral and inhaled medications. The beneficiary had stable vital signs. Her lungs were clear. Regarding rehabilitation services, the beneficiary received PT in the hospital. The beneficiary was at a supervision to independent level with functional mobility including gait to 60 feet with a rolling walker.There are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs; however, these do not require daily therapy services. This beneficiary does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facilitysetting.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-approveadmission to a skilled nursing facility (SNF).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit, testing and varicose vein treatment to be provided by an out of network (OON) provider.You asked the Plan to pre-approve an office visit, testing and varicose vein treatment. You say that you would like approval for these services with an out-of-network provider.The Plan denied your request. The Plan says there are multiple in-network providers that can provide these services.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-approvean office visit, testing and varicose vein treatment to be provided by an out of network (OON) provider.