Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the lateral sacral branches.

You asked the Plan to pre-approve the RFA. 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 RFA. Our reviewer says that the requested RFA is not considered medically reasonable and necessary in this case. Our physician reviewer found that this is considered an experimental/investigational procedure because of the wide variation in efficacy in the peer reviewed literature. Therefore, the procedure is deemed not medically reasonable or necessary.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the RFA have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the lateral sacral branches.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health services.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says Arguments of Initial Review Entity
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 services. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found the records do not show that skilled nursing services are required to effectively provide treatment, care, and/or services in order to improve the patient's condition, or to establish/perform a maintenance program to maintain your condition and/or prevent deterioration. Your conditions are chronic, and do not require a professional skilled nurse. There is no evidence of complex wound care. Without the need for skilled nursing or skilled therapy services home health aide services are not indicated per Medicare guidelines. 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 home health services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the enrollee needs the rehab being requested so that she can return to her maximum level of function.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 above.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee was medically stable with no evidence of need for supervision by a physical medicine and rehabilitation physician. There is no evidence of a need for acute rehab nursing care. Functionally, given her current level, she does not require IRF level of therapies. The enrollee may benefit from further physical therapy and occupational therapy, but does not require an intensive therapy program. IRF admission is not medically necessary based on the enrollee's current functional status and medical stability.We looked at this physician's review, the file, andMedicare 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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Roux-en-Y gastric bypass for the enrollee.You asked the Plan to pre-approve the surgery. You say that multiple studies show that this procedure is not only an acceptable alternative, but superior in many cases.The Plan denied your request. The Plan says they have determined that the requested service is not proven safe and effective, therefore, it 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 surgery. Our reviewer says that the requested surgery is not considered medically reasonable and necessary in this case. Our physician reviewer found there is insufficient information to determine medical necessity of conversion of failed nissen to gastric bypass. There is no information to determine BMI. Even if gastric bypass is used to treat a condition other than morbid obesity, dietary and lifestyle consequences will result. Therefore, both dietary and psychological evaluations would be necessary to determine if this enrollee would be a reasonable candidate. Weight loss would ensue, and therefore, this enrollee may not be an appropriate candidate depending on the BMI.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 surgery have not been met.Therefore, we decided that the Plan does not have to pre-approve Roux-en-Y gastric bypass for the enrollee.
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 enrollee would benefit from IRF care. The Plan denied your request. The Plan says the enrollee's needs could be met at a lower level of care.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found based on the records provided, the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. 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: 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 haven not been met. The Plan says that the services needed can be provided in an alternate 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 above. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee had surgery to repair perforated sigmoid colon. There are no complex wound care needs and no documentation of other complex medical needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. Although the enrollee does have a documented need for physical and occupational therapy, the submitted documentation does not support a need for intensive rehabilitation. 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 therapy notes describe tolerance for only a 24 minute session of therapy. 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: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve capecitabine tablets.You asked the Plan to pre-approve the capecitabine. You say that the enrollee's cancer needs immediate treatment but the source cannot be confirmed. This drug is used successfully for cancers of unknown origin and may improve her condition and quality of life.The Plan denied your request. The Plan says that this is not approved for the enrollee's diagnosis.The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 capecitabine. Our reviewer says that the use of the requested drug is considered medically reasonable and necessary. Our physician reviewer found the enrollee is a female with a recent diagnosis of adenocarcinoma of unknown primary with liver and bone metastases. It is of suspected GI origin though this cannot be confirmed. She does have a history of triple negative breast cancer in 2005 and has never smoked.Though this drug is not FDA-approved for this condition, the Medicare compendia list this drug as supported for off-label use for cancers of unknown primary. As such, this is considered medically reasonable treatment for this enrollee.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 capecitabine have been met.Therefore, we decided that the Plan has to pre-approve capecitabine tablets.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: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a CT scan.You asked the Plan to pre-approve a CT scan. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says that the requested services are not medically necessary.The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a CT scan. Our reviewer says that the documentation supports that the requested CT scan is medically reasonable or necessary. Our physician reviewer found you have a history of coronary artery disease, arthritis and aortic valve stenosis scheduled for possible transcutaneous aortic valve replacement. The documentation from June 25, 2020 documents dyspnea and intermittent chest pain. Based on the limited records, you have symptomatic aortic valve stenosis being considered for transcatheter aortic valve replacement. In this circumstance and assessment of vasculature from the inguinal area to the chest with CT scanning is standard and medically necessary to determine if the arterial vessels can accommodate the aortic valve being inserted, especially given increased risk of coexisting arterial vascular disease. Therefore, you meet criteria for the requested CT scan.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 CT scan have not been met.Therefore, we decided that the Plan has to pre-approvea CT scan.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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for 96367-59 (1 unit)-provided on October 31, 2019.
You asked the Plan to pay for 96367-59 (1 unit) - intravenous infusion, for therapy, prophylaxis, or diagnosis; additional sequential infusion of a new drug/substance, up to 1 hour. You say that the Plan should pay this claim. The Plan denied your request. The Plan says the billed services were not supported in the documentation submitted.
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units provided for each procedure code. We find that the documentation submitted was reviewed and the infusion report does not indicate that an additional sequential infusion of a new drug substance was given. Based on this information, we decided that Medicare rules for coverage of 96367-59 (1 unit) - intravenous infusion, for therapy, prophylaxis, or diagnosis; additional sequential infusion of a new drug/substance, up to 1 hour have not been met. Therefore, we decided that the Plan does not have to pay for 96367-59 (1 unit)-provided on October 31, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a medial branch block.
You asked the Plan to pre-approve medial branch block. You say that you are in intense pain and need these injections. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because previous diagnostic medial branch block were not successful as there is no documented evidence of greater than 80% pain relief.
The Plan follows Medicare rules. Medicare rules say that radiofrequency medial branch neurotomy may be considered only when diagnostic medial branch blocks provide greater than 80% relief of the 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 medial branch block. Our reviewer says that you do not meet the Medicare criteria for the requested medial branch block. Our physician reviewer found there is no documented evidence of greater than 80% pain relief with previous injections. They did not help with pain at all per your documented statement. You have no radicular symptoms, examination was essentially normal, and pain is mechanical, not axial. There is no evidence of any fracture, tumor, infection, or significant deformity. Previous medial branch blocks have not resulted in either temporary, long-lasting, or permanent relief of facet-mediated 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 medial branch block have not been met. Therefore, we decided that the Plan does not have to pre-approve a medial branch block.
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-approve hematology-oncology consultation. You say that you wish to seek a second opinion before proceeding with any sort of treatment, as your treatment should not be based off of one medical opinion. You also say that this provider mentioned that they have a lot of patients from your Plan.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 you can receive a second opinion from an in-network specialist.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 the medical services to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the coinsurance for the heart procedure provided on May 7, 2020.
You asked the Plan to waive the coinsurance for the heart procedure provided on May 7, 2020. You say that you were unaware you had a coinsurance for this procedure. You say you cannot afford this bill. The Plan denied your request. The Plan says that you have been charged the correct cost sharing amount.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The plan did not submit the Explanation of Benefits showing the application of the coinsurance amount for this service. Therefore, the plan has not shown that the coinsurance amount you are being asked to pay is correct or justified by the health plan contract. Therefore, we decided that the Plan has to waive the coinsurance for the heart procedure provided on May 7, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve external mobile cardiovascular telemetry.You asked the Plan to pre-approve the services. You say that the plan should reconsider coverage.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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found based on the provided records, there is no documentation of palpitations, presyncope, syncope, arrhythmia or other indication for arrhythmia evaluation.  Moreover, if cardiac monitoring were thought to be medically necessary to evaluate for dysrhythmia then non-real time (off-line) monitoring devices such as Holter monitoring or extended (30-day) event monitoring should be sufficient for identification of both symptomatic and asymptomatic dyshrythmias. There is no documentation to indicate the enrollee is not able to effectively manage these standard monitoring devices and no indication that these have been previously obtained to evaluate the enrollee's condition. Current expert consensus guidelines endorsed by several national organizations also consider patient activated event recorders and other off-line monitoring devices appropriate initial tests for evaluation of dysrhythmias. Continuous real-time monitoring by telemetry services is not medically necessary, since off-line analysis of a patient-activated and/or auto-triggered device should be sufficient to identify dysrhythmias without jeopardizing patient safety.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 external mobile cardiovascular telemetry
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a surgical extraction of tooth #15 (D7250).
You asked the Plan to pre-approve the surgical extraction of tooth #15 (D7250). You say that the service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary
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. The Plan covers the surgical extraction of tooth #15 (D7250) when the services are medically necessary and reasonable. 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 surgical extraction of tooth #15 (D7250). Our reviewer says that the service is not medically necessary. Our physician reviewer found that the x-ray reveals a heavily decayed tooth #15, with some coronal structure remaining. Our physician reviewer says there has been no prior attempted extraction of tooth #15. Our physician reviewer says that the billed code would not be the most appropriate code. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the surgical extraction of tooth #15 (D7250) have not been met. Therefore, we decided that the Plan does not have to pre-approve the surgical extraction of tooth #15 (D7250).