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

We decided that the Plan does not have to pre-approve Outpatient Surgery Intracept procedure (CPT code(s): 22899 and C9752), 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 medical studies have not proven that the device(s) 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 the services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the intracept procedure remains experimental for the treatment of low back pain. More research is needed to how safety and efficacy of the intracept 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve Outpatient Surgery Intracept procedure (CPT code(s): 22899 and C9752), for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation.

You asked the Plan to pre-approve additional trips. You say that the enrollee is on dialysis and needs transportation. The Plan denied your request. The Plan says you have used 48 trips for this service.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 48 one-way trips per year. 

We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the enrollee has exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex Superion interspinous spacer device (22869, 22870).
You asked the Plan to pre-approve the Vertiflex Superion device. You say that the records provided should support the necessity of the service in dispute. The Plan denied your request. The Plan says this service is considered experimental and investigational as it has not been shown to be safe and effective.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The rules also say that experimental and investigational devices are not covered. We looked at this the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Vertiflex Superion device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex Superion interspinous spacer device (22869, 22870).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve placement of the CardioMEMS device.
You asked the Plan to pre-approve the CardioMEMS procedure. You say that this treatment is necessary to reduce hospitalizations related to heart failure. The Plan denied your request. The Plan says there is insufficient evidence of clinical benefit from this procedure.
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 CardioMEMS procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the CardioMEMS HF System is indicated for wirelessly measuring and monitoring pulmonary artery (PA) pressure and heart rate in New York Heart Association (NYHA) Class III heart failure patients who have been hospitalized for heart failure in the previous year. The available documentation is insufficient to demonstrate that the enrollee was hospitalized for heart failure. 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 CardioMEMS procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve placement of the CardioMEMS device.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve shoulder bone shaving and release of bicep tendon for the enrollee.
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that these services are 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 these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. The enrollee is being treated for complete rotator cuff tear, left shoulder. The enrollee notes ongoing issues in the left shoulder. He has had increasing pain. He is getting sharp pains and then pain whenever he lifts out to the lateral side. He has been getting progressively worse. He has pain at night and difficulty sleeping. Pain is rated currently at 1 or 2 out of 10, but as high as a 7 or 8 out of 10 at its worse. Exam of his left shoulder reveals forward flexion up to 160, abduction to 90, internal rotation to waistline. There is pain and weakness with isolated supraspinatus testing. The MRI formal imaging report does not demonstrate any biceps subluxation or acromioclavicular joint showing only minor degenerative changes with inferior spurring component. There is some component of impingement up on the supraspinatus muscle and tendon, no indication of any abnormal configuration or downsloping of the acromion process to contribute to any outlet compromise. Overall, detailed documentation is not evident regarding objective findings that support the pathology. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for these services. 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 pre-approve shoulder bone shaving and release of bicep tendon 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 it is felt that IRF care would be best to let you regain strength. The Plan denied your request. The Plan says criteria for IRF care are not met.

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 patient was admitted for chemotherapy for head and neck cancer. Medical problems are stable. There are no complex nursing or rehabilitation needs. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. 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. 

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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT code 22869), for the enrollee.
You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your request. The Plan says the service is considered experimental and investigational.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the service. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex superion spacer is experimental. More research is needed to show safety and efficacy of the device. Open laminectomy is the gold standard for lumbar decompression. 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 the Vertiflex superion device placement surgery (CPT code 22869), for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vertiflex Superion device placement surgery (22869).
You asked the Plan to pre-approve Vertiflex Superion device. You say that you hope for a favorable outcome to approve this preauthorization request and provide the necessary coverage that the enrollee should be entitled to. The Plan denied your request. The Plan says this device is investigational and experimental, and the enrollee is not receiving this device as part of a Medicare covered clinical trial.
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. Based on this information, we decided that Medicare rules for coverage of Vertiflex Superion device have not been met. Therefore, we decided that the Plan does not have to pre-approve Vertiflex Superion device placement surgery (22869).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Lumbar Fusion - Multi-Level (Low Back Surgery)
(CPT code 22614) 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 not 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 items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found there is no documentation of disabling symptoms for more than six (6) months and there is a
normal neurologic exam documented. Also, there is no spinal instability, fracture, or lesion documented.
Criteria for spine surgery 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 the services have not been met. Therefore, we decided that the Plan does not
have to pre-approve Lumbar Fusion - Multi-Level (Low Back Surgery) (CPT code 22614) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis provided on October 3, 2020.
You asked the Plan to pay for the lumbar-sacral orthosis. You say that you would like the plan to reconsider
their denial. The Plan denied your request. The Plan says the services billed are not payable.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services,
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for
telehealth services only if they are presented from an authorized originating site located in either a county
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located
in a rural census tract.
A review of the file does not show that the telehealth service was provided in an authorized originating site.
The documentation does not support that the enrollee received a video or telephonic visit by the ordering
physician. In addition, there were no claims on file for this enrollee from the ordering physician. This means
that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an inperson
encounter.
Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore,
we decided that the Plan does not have to pay for the lumbar-sacral orthosis provided on October 3, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Factor II Prothrombin testing.
You asked the Plan to pre-approve Factor II Prothrombin testing. You say that you would like reconsideration because you are in a vulnerable situation due to multiple relatives dying from this disease. The Plan denied your request. The Plan says this service is not covered because you are not pregnant.
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 Factor II Prothrombin testing. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not describe unusual circumstances whereby the results of the test will affect your clinical management. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Factor II Prothrombin testing have not been met. Therefore, we decided that the Plan does not have to pre-approve Factor II Prothrombin testing.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the oscillating leg vibrator.
You asked the Plan to pre-approve the oscillating leg vibrator. You say that this device is necessary for your condition. The Plan denied your request. The Plan says this is not a covered item.
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-approve the oscillating leg vibrator.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says medical studies have not proven that this device is helpful for treatment of the 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 the device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the interspinous spacer 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 the device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion of an interspinous spacer device (Vertiflex).
You asked the Plan to pre-approve Vertiflex. You say that you are appealing based on medical necessity. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because Vertiflex is experimental/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 Vertiflex. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental. More research is needed to show its 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 Vertiflex have not been met. Therefore, we decided that the Plan does not have to pre-approve insertion of an interspinous spacer device (Vertiflex).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve immunizations.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your
request. The Plan says this is not a covered benefit.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the services. The
Plan follows the same rules.
Records do not show that you have been injured or directly exposed to any illness related to the services.
Therefore, we decided that the Plan does not have to pre-approve immunizations.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve gastroenterology services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve gastroenterology services. You say that the member's primary care physician referred this provider. You say that you would like approval for these services to be provided out-of-network. 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 gastroenterology 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 a maxillary partial denture and a mandibular partial denture.
You asked the Plan to pre-approve the maxillary partial denture and mandibular partial denture. You say that you would like these services approved for coverage. The Plan denied your request. The Plan says these 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 requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a maxillary partial denture and a mandibular partial denture.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve in-network coverage for other evaluation and management services (99499) to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve the other evaluation and management services. You say that your entire family lives in the Columbus Ohio area and your daughter would like you to stay with them during this time period of these radiation treatments. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.

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 in-network coverage for other evaluation and management services (99499) 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 custom fabricated abutments (D6057) for teeth #'s 19,
23, 26, and 30 and abutment supported porcelain fused to metal crowns (D6061) for teeth #'s 19, 23, 26, and
30.

You asked the Plan to pre-approve the custom fabricated abutments and abutment supported porcelain fused to
metal crowns. You say that you would like these services to be approved for coverage. The Plan denied your
request. The Plan says these services are not covered under your benefit plan.

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
custom fabricated abutments (D6057) for teeth #'s 19, 23, 26, and 30 and abutment supported porcelain fused
to metal crowns (D6061) for teeth #'s 19, 23, 26, and 30.