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

We decided that the Plan does not have to pay for the surgical trays used during a medical procedure provided on December 31, 2019 billed with code A4550.
You asked the Plan to pay for the surgical trays. You say that this provider is credentialed and should be paid for services rendered. The Plan denied your request. The Plan says this claim was denied as the provider's license was not active. Upon review, it was found that payment could be made aside from code A4550.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. CPT code A4550 has a status indicator of "B" in the Physician Fee Schedule. This means that payment is always bundled with payment made for other services provided. Based on this information, we decided that Medicare rules for coverage of the surgical trays have not been met. Therefore, we decided that the Plan does not have to pay for the surgical trays used during a medical procedure provided on December 31, 2019 billed with code A4550.
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 IRF care is medically necessary. The Plan denied
your request. The Plan says the guidelines for coverage 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 does not require the intensity of services provided at an IRF.
Specifically, the enrollee is not shown to be able to perform fifteen hours per week of rehabilitative services
and regular physician evaluation. 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Eliquis 5mg tablet medication.
You asked the Plan to pre-approve this medication. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says this medication is not a covered benefit under the member's contractual policy.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drug requested here is not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve the Eliquis 5mg tablet medication.
Benefits for this medication 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 this is medically necessary. The Plan denied your
request. The Plan says your needs can 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 submitted records, you do not meet criteria for coverage for an IRF
admission. You are generally stable with metastatic prostate cancer and debility with no recent neurological or
orthopedic events and there is no evidence of complex medical issues that require monitoring by an inpatient
physician three times per week or need for acute rehab nursing care. You have low tolerance for therapies.
While you may benefit from continuing physical and occupational therapy, there is no evidence of a need for
an intensive therapy program with therapy 3 hours per day with frequent physician oversight and an
interdisciplinary approach to rehabilitation 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says the services can be safely received in other settings.
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 is medically stable, with no evidence of need for supervision by a PMR physician. There is no need for acute rehab nursing care. Functionally she would not benefit or tolerate from IRF therapies, due to a low functional level. The enrollee may benefit from further PT and OT 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, 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 admission to an inpatient rehabilitation facility (IRF) 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 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 records do not indicate that there are significant, or complex medical/nursing issues
that could not be addressed at a skilled nursing facility (SNF) level of care. Ongoing medication management,
skin/wound care, and daily therapy can be provided at a SNF. In this case, the enrollee is mostly maximum
assist for functional transfers and activities of daily living (ADL's) and a less intensive, longer duration of
therapy may be more appropriate. It is not clear the enrollee would be able to fully benefit and/or participate in
an IRF 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: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Durolane (J7318).
You asked the Plan to pre-approve Durolane. You say that this is medically necessary. The Plan denied your
request. The Plan says step therapy requirements have not been met.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain
Part B medications.
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 Durolane. Our reviewer says that the
criteria for coverage of Durolane has not been met. Our physician reviewer found the Plan requires a trial of
drug Monovisc and Orthovisc before they will approve the requested drug. The documentation does not
support that the enrollee has tried Monovisc and Orthovisc, or that these drugs would likely be less effective or
have adverse effects for the enrollee in this case.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Durolane have not been met. Therefore, we decided that the Plan does not have
to pre-approve Durolane (J7318).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a second opinion to be provided by an out of network
(OON) provider.
You asked the Plan to pre-approve a second opinion to be provided by an OON provider. You say that the
service is necessary. The Plan denied your request. The Plan says there are in-network providers that are able to
provide this service. Therefore, coverage criteria has not been met.
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 second opinion to be provided by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for adjacent tissue transfer (14301 and 14302) provided on December 18, 2019.
You asked the Plan to pay for adjacent tissue transfer. You say that these codes are documented in the report. The Plan denied your request. The Plan says these codes are not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 14301 is adjacent tissue transfer or rearrangement, any area; defect 30.1 sq cm to 60.0 sq cm, and 14302 is adjacent tissue transfer or rearrangement, any area; each additional 30.0 sq cm, or part thereof (List separately in addition to code for primary procedure). 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 adjacent tissue transfer. Our reviewer says that these codes are not supported. Our physician reviewer found the documentation included in the medical record does not document a description in the operative note that describes an adjacent tissue transfer or rearrangement, any area; defect 30.1 sq cm to 60.0 sq cm or an adjacent tissue transfer or rearrangement, any area; each additional 30.0 sq cm, or part thereof. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of adjacent tissue transfer have not been met. Therefore, we decided that the Plan does not have to pay for adjacent tissue transfer (14301 and 14302) provided on December 18, 2019.
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 this is medically necessary. The Plan denied your
request. The Plan says it has not been demonstrated that you can participate in three hours of therapy, and that
acute care is needed three times a week.
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 your nursing, medical and rehabilitation needs do not require an
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require
treatment in an intensive rehabilitation therapy program. Care at the skilled nursing facility level appears to be
more appropriate in this case.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a PureWick external catheter and supplies.
You asked the Plan to pre-approve the PureWick and supplies. You say that you would like reconsideration
because no other method has worked for the member. The Plan denied your request. The Plan says this supply
is not a Medicare covered benefit.
The Plan must follow Medicare rules. The rules state that durable medical equipment is equipment which:
- Can withstand repeated use;
- Is primarily and customarily used to serve a medical purpose; - Generally is not useful to a person in the
absence of an illness or injury; and
- Is appropriate for use in the home.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the PureWick and supplies have not been met. Specifically, this supply is not a Medicare covered
benefit and does not meet the Medicare definition of durable medical equipment. Therefore, we decided that
the Plan does not have to pre-approve a PureWick external catheter and supplies.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve spinal fusion surgery.
You asked the Plan to pre-approve spinal fusion surgery. 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. 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 spinal fusion surgery. Our reviewer
says that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found the enrollee has ongoing symptoms from his degenerative grade 1 L4-5
spondylolisthesis with a tight stenosis. The documentation does not clearly document spinal instability. There
are no flexion and extension films showing abnormal motion. Therefore, the enrollee does not meet criteria for
the requested fusion services.
Review of the file shows that the plan uses Local Coverage Determination, LCD L37848 to support their
denial. However, LCD is not valid for the enrollee's home state of Michigan. Therefore, we cannot use LCD
L37848 to substantiate our decision.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of spinal fusion surgery have not been met. Therefore, we decided that the Plan
does not have to pre-approve spinal fusion surgery.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued use of an Optune device for tumor treatment
field therapy (TTFT)(E0766).
You asked the Plan to pre-approve continued use of an Optune device for TTFT. You say that this is medically
necessary. The Plan denied your request. The Plan says the enrollee only uses the device 47% of the time.
The Plan follows Medicare rules. Medicare rules say that continued coverage of TTFT (E0766) beyond the first
three months of therapy requires that objective evidence of adherence to therapy, defined as the use of TTFT
for an average of 18 hours per day (excluding days the treating practitioner has documented a medical need to
limit or interrupt treatment).
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 continued use of an Optune device for
TTFT. Our reviewer says that the criteria for coverage of TTFT has not been met. Our physician reviewer
found the enrollee's overall usage for the time period of February 1, 2020 to March 1, 2020 was 47%. The
documentation does not support that the enrollee is adherent with use of TTFT for an average of 18 hours per
day. There is documentation of some unspecified technical issues with the Optune device. The treating
practitioner has not documented a medical need to limit or interrupt treatment. Consequently, continued
coverage of TTFT is not reasonable and 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 continued use of an Optune device for TTFT have not been met. Therefore, we
decided that the Plan does not have to pre-approve continued use of an Optune device for tumor treatment field
therapy (TTFT)(E0766).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Coflex interspinous spacer device.
You asked the Plan to pre-approve a Coflex interspinous spacer device. You say that the requested Coflex
interspinous spacer device is medically necessary. The Plan denied your request. The Plan says the requested
Coflex interspinous spacer device 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 a Coflex interspinous spacer device.
Our reviewer says that the requested Coflex interspinous spacer device is not medically necessary. Our
physician reviewer found the enrollee is with spinal stenosis. He has previously been approved L3-L5
discectomy/decompression. Following this appeal review the Plan further approved surgery to all requested
spinal levels: L2 to L5. The requested Coflex device, however, is experimental at this time. More research is
needed at this time.
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 Coflex interspinous spacer device have not been met. Therefore, we decided
that the Plan does not have to pre-approve a Coflex interspinous spacer device.
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 transfer to an LTACH is medically
necessary. The Plan denied your request. The Plan says Medicare criteria for transfer to an LTACH are not
met.
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 medical record documentation does not support that you require services at the
LTACH that are not available at the acute care hospital where you are currently receiving care. There are no
required medical services identified that are available at the LTACH, that are not available at the current health
care setting being offered by the health plan. Medicare coverage criteria are 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to preapprove
long term acute care hospital (LTACH) 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 for the enrollee.
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary. The Plan denied
your request. The Plan says Medicare coverage 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 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 do not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's
current medical status does not require intensive physician or nursing oversight in an IRF. The enrollee's
functional level does not require or indicate that this therapy must be in an IRF with an intensive level program.
Medicare coverage criteria are 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 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 for the enrollee.