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

We decided that the Plan does not have to pre-approve lumbar medial branch blocks.
You asked the Plan to pre-approve the lumbar medial branch blocks. You say that you would like reconsideration because this procedure will be used to treat the member's lower back pain. The Plan denied your request. The Plan says there is no clinical information to indicate the member's source of pain.
The Plan follows Medicare rules. Medicare rules say that facet joint injections are indicated when specific 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 the lumbar medial branch blocks. Our reviewer says that before performing any interventional procedure a physical examination must be documented and the documentation only includes records of a telehealth visit. Our physician reviewer found performance of medial branch blocks at a prior laminectomy/formanotomy level is not supported by the literature. 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 lumbar medial branch blocks have not been met. Therefore, we decided that the Plan does not have to pre-approve lumbar medial branch blocks.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Testosterone.

You asked the Plan to pre-approve Testosterone. You say that you would like reconsideration because this drug
is medically necessary. The Plan denied your request. The Plan says this drug is not covered for the member's
condition under Medicare Part B.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered
drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Testosterone.

Benefits for Testosterone may be available under Medicare Part D. Contact the Plan that administers Part D
benefits for further information concerning any benefits and appeal rights.
Appeal type: 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 you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.

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 hospital for an elective repair of an aneurysm. The enrollee tolerated the procedure and remained stable medically. The documentation does not support that the enrollee requires an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not support that the enrollee requires an intensive rehabilitation therapy program. The enrollee's care needs can be met at a lower level of care.

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: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve a CardioMEMS device.

You asked the Plan to pre-approve a CardioMEMS device. You say that you would like reconsideration because the member meets indications for the CardioMEMS system.The Plan denied your request. The Plan says that the member is not receiving care in a facility that is enrolled in a Medicare approved Category B IDE study.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 CardioMEMS device. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found based on the FDA indications and published data from Champions trial along with expert opinion, the member would meet criteria for CardioMEMS implantation. The member has severe and complex conditions and has had regular medical follow-up and continuous conventional fluid management but they have been re-hospitalized twice recently despite this aggressive management of their 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 a CardioMEMS device have been met.Therefore, we decided that the Plan has to pre-approve a CardioMEMS device.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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve paravertebral facet joint nerve destruction for the enrollee.

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 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 there are multiple probable pain generators, and therefore, the request does not meet the criteria.

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 paravertebral facet joint nerve destruction for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network provider for a
prostatectomy.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your
request. The Plan says there is an in-network physician with the same skill set and similar distance to you.
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
a referral to an out-of-network provider for a prostatectomy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6549.
You asked the Plan to pre-approve the compression stockings. You say that this is needed to reduce the risk of chronic venostasis ulcers. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are noncovered because they do not meet the statutory definition of a surgical dressing. Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6549.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician's services to be provided by the out-of-network provider.
You asked the Plan to pre-approve the physician's services. The Plan denied your request. The Plan says you must receive your care from a network provider. In most cases, care you receive from an out-of-network provider will not be covered except for emergency or urgently needed services that you get from an out-of-network provider. If you need medical care that Medicare requires our Plan to cover and the providers in our network cannot provide this care, you can get this care from an out-of-network provider. A prior authorization is required if you are seeking non-emergency out-of-network care. The Plan covers kidney dialysis services that you get at a Medicare-certified dialysis facility when you are temporarily outside the Plan's service area.
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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve physician's services to be provided by the out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a protective restoration (D2940) and an interim partial denture (D5821).
You asked the Plan to pre-approve the restoration and temporary denture. You say that these services are necessary. The Plan denied your request. The Plan says these services are not covered by Medicare or by the Plan's supplemental dental benefit.
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 protective restoration (D2940) and an interim partial denture (D5821).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that the enrollee meets criteria for admission to an LTACH. The Plan denied your request. The Plan says the enrollee is receiving adequate care in the current setting.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 

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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the patient is a 67 year old female who was admitted to the current acute care hospital for bypass coronary heart surgery with mitral valve and tricuspid valve repairs complicated by acute kidney injury requiring dialysis and prolonged need for mechanical ventilation as well as wound infection required wound care and antibiotics, and anemia requiring blood transfusion, and hematoma in right psoas muscle. Also, stool was positive for blood. Recent notes show fever and is exhibiting severe agitation. She is still requiring tube feeds. 

The patient appears to be unstable and requires additional short term acute care services which can safely be completed at the current facility. The patient does not require services at the LTACH that are not already available at the current facility. There are no services at the LTACH that the patient requires that are not already available and covered at the current facility. Therefore, this request for LTACH services will be considered not medically necessary at this time. Transfer to a lower level of care may be considered when treatment has completed and when more stable. 

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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an outpatient dental extraction surgery (D41899) to be provided with anesthesia and covered under Medicare.

You asked the Plan to pay for a Medicare-covered dental extraction surgery. You say that it is necessary for these services to be covered under Medicare so that the related anesthesia that is required for these services can be covered as well. The Plan denied your request. The Plan says these services are excluded from coverage under Medicare.

Medicare generally does not cover dental services. The Plan offers some supplemental dental coverage for certain services, but you specifically requested that the Plan cover these services under the Medicare benefit rather than the supplemental dental benefit.

The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of the enrollee's teeth or the structures directly supporting the enrollee's teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for an outpatient dental extraction surgery (D41899) to be provided with anesthesia and covered under Medicare.

You may wish to contact the Plan regarding coverage or reimbursement of eligible services under the supplemental dental benefit.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a dental implant replacement (D6999).
You asked the Plan to pre-approve the implant replacement. You say that the replacement is medically necessary. The Plan denied your request. The Plan says this is not a covered service.
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 dental implant replacement (D6999).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the CardioMEMS device for the enrollee.
You asked the Plan to pre-approve the surgery. You say that this is medically necessary due to worsening heart failure. The Plan denied your request. The Plan says the enrollee is not in a Medicare-approved study that is looking at the benefits of this service.
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 services are not considered medically reasonable and necessary in this case. Our physician reviewer found in this case, the enrollee has a left ventricular assist device due to severe heart failure. The enrollee does not have class III 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 surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve the CardioMEMS device for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a SNF setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Sacroiliac joint radiofrequency ablation (64625).

You asked the Plan to pre-approve the joint ablation procedure. You say that the services are medically
necessary. The Plan denied your request. The Plan says this procedure is experimental and 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 joint ablation procedure. Our
reviewer says that the requested services are not considered medically reasonable and necessary in this case.
Our physician reviewer found this procedure is considered an investigational procedure because of the wide
variation in efficacy in the peer-reviewed literature.

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 joint ablation procedure have not been met. Therefore, we decided that the
Plan does not have to pre-approve Sacroiliac joint radiofrequency ablation (64625).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor.
You asked the Plan to pre-approve the monitor. You say that this is medically necessary. 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 monitor. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found you are only taking one shot of insulin daily. The plan criteria requires three shots daily, and insulin dose adjustments based on blood glucose levels. Furthermore, there is no information given as to why the glucometer use alone is not sufficient for your medical needs. 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 monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lumbar epidural injection.

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 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has multilevel bilateral facet Arthropathy and moderate neuroforaminal narrowing. The physical examination demonstrates bilateral facet loading. He has received muscle relaxants and opioid therapy. The provided documentation does not indicate the enrollee complains of back pain or radiculopathy. The services are therefore not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a lumbar epidural injection.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the molecular pathology service (81479) provided on November 3, 2020.
You asked the Plan to pay for the molecular pathology service. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the additional 3 units billed exceed Medicare's MUE value.
The Plan must follow Medicare rules. Medicare rules say that an MUE for a HCPCS/CPT code is the maximum number of units of service under most circumstances allowable by the same provider for the same enrollee on the same date of service. In this case, CPT code 81479 has a MUE of 3 and you have billed 6 units. 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 molecular pathology service. Our reviewer says that the additional 3 units of CPT code 81479 do not meet criteria for billing or reimbursement consideration. Our physician reviewer found there is no evidence to support that the provided service was medically necessary and reasonable to diagnose, treat or otherwise manage the enrollee's 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 molecular pathology service have not been met. Therefore, we decided that the Plan does not have to pay for the molecular pathology service (81479) provided on November 3, 2020.