Persius/hicric huggingface dataset:
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 the requested items are a necessity for your care. The Plan denied your request. The Plan says rules for durable medical equipment have not been met.
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genetic testing (CPT 81162, CPT 81479) for the enrollee.
You asked the Plan to pre-approve the testing. You say that this is medically necessary. The Plan denied your request. The Plan says there is no clinical evidence to support the medical necessity for this testing.
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 testing. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that in this case the record indicates that coverage for BRCA1, BRCA2, and an unlisted procedure code was requested. The record indicates that the enrollee has right breast cancer, ER/PR positive abd Her-2/neu negative undergoing staging and treatment. The records provided do not indicate that the results of the testing will change the current treatment or management of the enrollee. The records do not indicate how the risk assessment would change the management of the 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 testing have not been met. Therefore, we decided that the Plan does not have to pre-approve genetic testing (CPT 81162, CPT 81479) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a stair lift chair.
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 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. Therefore, we decided that the Plan does not have to pre-approve a stair lift chair.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Farxiga tablet 10mg for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says there are no Medicare Part D benefits. 
 
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 Farxiga tablet 10mg for the 
enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Botox (onabotulinumtoxina) injections, every 12 weeks for 12 months.
You asked the Plan to pre-approve Botox injection. You say that the requested injection is medically necessary. The Plan denied your request. The Plan says Botox must be supplied by your doctor or a health care facility. The Plan also says that drugs supplied by a pharmacy are not covered by Part B Medicare.
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be brought to the office for administration. Since the medication does not represent an expense to the physician and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that the Plan does not have to pre-approve Botox (onabotulinumtoxina) injections, every 12 weeks for 12 months.
Benefits for Botox injection 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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve eight additional home physical therapy visits (two visits a week for four weeks).
You asked the Plan to pre-approve the home physical therapy visits. You say that if you do not get enough therapy your leg may have to be amputated. The Plan denied your request. The Plan says the services are not necessary.
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 home physical therapy visits. Our physician reviewer found the health plan's denial should be upheld. You do not have documented skilled therapy needs. As such, the requested ongoing home health physical therapy services are not medically necessary or reasonable. 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 home physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve eight additional home physical therapy visits (two visits a week for four weeks).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CALR, MPL, and CSF3R genetic testing.
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. Medicare rules say that CALR and MPL genetic testing is covered for specific indications only. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. We looked at the file and Medicare rules. The file shows that the enrollee does not have a condition for which CALR and MPL genetic testing is covered. The requested CSF3R testing is being requested for screening purposes. 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 CALR, MPL, and CSF3R genetic testing.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for medical services provided to the enrollee on October 1, 2020 and billed under code 99199-59.
You asked the Plan to pay for this these services. You say that this claim should be paid. The Plan denied your request. The Plan says this code was not billed in accordance with Medicare coding regulations. The Plan says that code 99199 cannot be billed by an anesthesia practitioner. The Plan states that Per NCCI policy Chapter 2, Anesthesia services must be billed with codes between 00100-01999 when billed by an anesthesia practitioner. Therefore, this claim cannot be paid as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. In this case code CPT code 99199-59 cannot be paid as billed due to a billing practitioner error. Medicare billing criteria are not met. Therefore, we decided that the Plan does not have to pay for services billed to the enrollee for October 1, 2020 under code 99199-59.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. 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 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 enrollee was admitted with sepsis from aspiration pneumonia. The record 
indicates the enrollee has a stable tracheostomy and requires oxygen for humidification only. The enrollee is 
being fed via a PEG tube. The enrollee continues to receive acute care services, and these have not been denied. 
The record does not indicate that the enrollee requires further acute care services. The medical record does not 
indicate that the enrollee requires services that the enrollee is not currently receiving but that would be 
available at the LTACH facility. The elements of the coverage rules are not satisfied. The requested service 
cannot be recommended. 
 
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 LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Arestin, 1 mg.
You asked the Plan to pre-approve Arestin. You say that the requested drug is necessary. The Plan denied your request. The Plan says Arestin is used as part of a routine dental service. The Plan also says that routine dental services are not covered by Medicare.
Medicare generally does not cover dental services. The Plan follows the same rule.
The services you are asking the Plan to pre-approve 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. Though the Plan offers a dental benefit in excess of Medicare coverage, the service you are asking the Plan to pre-approve involves 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 pre-approve Arestin, 1 mg.
Benefits for Arestin 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda (CPT code J9271), for the enrollee.
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied your request. The Plan says the medication is not necessary.
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 medication. Our physician reviewer found the record indicates that the enrollee has angiosarcoma of lung. The enrollee progressed on paclitaxel and responded to doxorubicin as second line therapy. The Medicare approved cancer compendia do not contain supportive citations for the use of the requested drug in the enrollee's specific clinical scenario. No literature from Medicare approved caner journal compendia was submitted for review. The elements of the coverage criteria are not satisfied. The requested service cannot be recommended. 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 medication have not been met. Therefore, we decided that the Plan does not have to pre-approve Keytruda (CPT code J9271), 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 services 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. 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 complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. You do require physical and occupational therapy but there is no documented 
need for an intensive rehabilitation program. Medically necessary services can be provided in a different level
of care. There is not a reasonable expectation that you 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: Favorable

We decided that the Plan has to pre-approve the CardioMEMS device (CPT code(s): 33289 and C2624), for the enrollee.
You asked the Plan to pre-approve the CardioMEMS device. You say that the enrollee urgently needs this device and procedure due to their worsening heart failure. The Plan denied your request. The Plan says that the services are considered experimental and investigational.
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 the CardioMEMS device. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found there is a published expert opinion in the cardiology literature as to its appropriate use (2) as well as reasonable patient selection criteria (3), and FDA approved indications (4) all of which are met in this clinical instance. Given the severe symptoms of recurrent congestive heart failure (CHF) which appears very sensitive to volume loading conditions, complexity of the medical regimen and the failure to prevent acute CHF hospitalization in this enrollee, use of the CardioMEMS device is reasonable and has clinical data, expert opinion, and approved Food and Drug Administration (FDA) indications to back up its use in selected appropriate clinical situations like this one. It would therefore not be considered investigational for this indication and meets the medical reasonableness and necessity criteria of the applicable CMS Section 1862(a) 1(A) rule. 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 device have been met. Therefore, we decided that the Plan has to pre-approve the CardioMEMS device (CPT code(s): 33289 and C2624), for the enrollee.
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve complete upper and lower dentures.

You asked the Plan to pre-approve these services. You say that your dentures are in disrepair. The Plan denied your request. The Plan says the request exceeds the benefit limit.

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 upper and lower dentures once every five years. 

We looked at the file and Medicare rules. The file shows that you previously received complete upper and lower dentures on December 30, 2020. You are not eligible for new dentures until five years have passed from this date. Based on this information, we decided that the Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve complete upper and lower dentures.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a prefabricated knee orthosis (L1845).
You asked the Plan to pre-approve the orthosis. You say that if the enrollee is unable to get this brace and continues to have symptoms related to her medial compartment arthritis, her next option will be a total knee arthroplasty. The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria for this brace.
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 orthosis. 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 evidence of a recent injury or surgery to the knee or evidence of objective instability or laxity on a recent knee exam. The requested L1845 knee orthosis is not 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 the orthosis have not been met. Therefore, we decided that the Plan does not have to pre-approve a prefabricated knee orthosis (L1845).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an electrical bone growth stimulator.
You asked the Plan to pre-approve an electrical bone growth stimulator. You say that the requested item is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met because the requested treatment is not medically necessary.
The Plan must follow Medicare rules. The rules say that an electrical bone stimulator is covered for failed fusion where a minimum of 9 months has elapsed since the last surgery. 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 an electrical bone growth stimulator. Our reviewer says that the requested item is not medically necessary. Our physician reviewer found that detailed documentation is not evident regarding a previously failed spinal fusion at the same site or a fusion to
be performed at multiple levels. Detailed documentation is not evident regarding the enrollee being at high risk of pseudoarthrosis due to previously failed spinal fusion at the same site or for those undergoing multilevel level fusion, involving 3 or more vertebrae. There is no compelling rationale presented or detailed extenuating circumstances noted to support the medical necessity of this request as an exception to 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 an electrical bone growth stimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve an electrical bone growth stimulator.
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 a review of the current medical literature indicates that this 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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the requested device is experimental. More research is needed. 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.