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

We decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung cancer screening.

You asked the Plan to pre-approve the requested LDCT scan. You say that you feel that the low-dose CT scan should be done for surveillance, and not a standard CT scan. The Plan denied your request. The Plan says LDCT is only covered for lung cancer screening. As the criteria for this screening are not met, the LDCT is not covered.

The Plan must follow Medicare rules. The rules say that Medicare covers one annual LDCT scan for lung cancer screening for enrollees who meet all the above described criteria. 

We reviewed the file and the Medicare rules. We find that the enrollee does not have a smoking history as required by the NCD, and due to the presence of a pulmonary nodule, is not asymptomatic.. Therefore, we decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung cancer screening.
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 is ready to go to the LTACH. The Plan denied your request. The Plan says the services are 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 medically necessary. Our physician reviewer found the enrollee was admitted to the hospital with nausea and vomiting, chest heaviness, and palpitations related to atrial fibrillation. She also had an acute kidney injury with anemia and positive stool occult blood test. She is improving and does not require services at the LTACH that are not already being provided at the current facility. There are no services at the proposed LTACH that she requires that are not already available and covered at the current facility. The LTACH services are 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 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve surgery to place a Vertiflex Superion device (CPT Code 22869).

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 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 services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the spacer is experimental. More research is needed to show safety and efficacy of the device. 

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 surgery to place a Vertiflex Superion device (CPT Code 22869).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long 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 there is no documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where they are currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 

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 LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee has reached maximum potential.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 the services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no recent nursing notes to document skilled needs. By the dates in question, there are no recent notes to document current functional status or skilled needs. You do not require skilled nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 the services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient hospital admission after right shoulder joint replacement surgery (arthroplasty), for the enrollee.

You asked the Plan to pre-approve acute inpatient hospital care. You say that this is a major elective surgery and usually involves a one-night stay in the hospital. The Plan denied your request. The Plan says this service is not listed on the inpatient only list.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. The planned procedure listed under Current Procedural Terminology (CPT) code 23472 is not listed on the CMS Inpatient Only List. The procedure is currently approved as an ambulatory procedure. There is no documentation provided to support the expectation the enrollee will require a greater than 2 midnight stay. If the enrollee experiences any peri- or post-operative complications, reconsideration for inpatient level of care can be performed on concurrent review with updated clinical information. Therefore, we decided that the Plan does not have to pre-approve inpatient hospital admission after right shoulder joint replacement surgery (arthroplasty), for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the cervical spine and shoulder.

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 MRIs are covered only when they are medically necessary. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has shoulder and neck pain. There is no clinical rationale for the requested MRI studies. There is no provided documentation showing that the enrollee has undergone or completed conservative management prior to proceeding with MRI of the shoulder and neck. Documentation of activity modification, anti-inflammatories, bracing, physical therapy, and/or home exercise program is necessary to proceed with MRI evaluation. In addition, the enrollee has a previous upper extremity MRI one year ago. The services are 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 magnetic resonance imaging (MRI) of the cervical spine and shoulder.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve placement of the Superion interspinous spacer.

You asked the Plan to pre-approve the Superion procedure. You say that it is felt that this procedure would benefit the enrollee. The Plan denied your request. The Plan says there is not sufficient information in the literature to support 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 Superion procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the spacer device is 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 Superion procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve placement of the Superion interspinous spacer.
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 these services are medically
necessary. The Plan denied your request. The Plan says there is not sufficient evidence of the medical necessity
of 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 therapy change based on data obtained from a CardioMEMS device has
been demonstrated in only one randomized prospective trial to help reduce hospital readmission compared to
standard medical therapy. Moreover, concerns have been raised about potential bias in this trial calling into
question the results. Therefore, the efficacy of the CardioMEMS device is uncertain at this time according to
leading authorities and not recommended in current guidelines for the treatment of heart failure. Medicare
coverage criteria are not met, since the device should still be considered experimental or investigational.

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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a mammography provided on October 26, 2020.

You asked the Plan to pay for the mammography. The Plan denied your request. The Plan says the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they approved in advance.

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 pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the mammography. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for a mammography provided on October 26, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the lumbar spine.

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 CT scans are covered only when they are medically necessary. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has low back pain. Magnetic resonance imaging (MRI) of the spine from 2017 shows multilevel degenerative disc disease but no significant canal or foraminal stenosis at the lumbar spine levels. Recent notes were not provided to show objective evidence of changes in physical findings to justify CT. Therefore, the lumbar spine CT is 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 computed tomography (CT) scan of the lumbar spine.
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. The Plan denied your request. The Plan says the enrollee's condition is not complex enough to require daily physician management.

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 physician reviewer found that you were admitted to the current acute care hospital with acute respiratory failure and aspiration pneumonia requiring mechanical ventilation, breathing treatments, antibiotics, and later tracheostomy and PEG placement. Recent notes show you are tolerating weaning, and are becoming more alert. You appear to be improving and only requires short term additional acute care services, which can be safely completed at the current facility. You do not require services at the LTACH that are not already being provided at the current facility. Therefore, this request for LTACH services is not supported and will be considered 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 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve electronic muscle stimulation, ultrasound, and other
chiropractic services.

You asked the Plan to pre-approve electronic muscle stimulation, ultrasound, and other chiropractic services.
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 the only chiropractic service Medicare covers is
manual manipulation of the spine to correct a subluxation.

The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that
the Plan does not have to pre-approve electronic muscle stimulation, ultrasound, and other chiropractic
services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the BLS emergency ambulance (A0429) and ground mileage A0425).

You asked the Plan to pay for the ambulance services. You say that you had no other way to get to the hospital. Please reconsider coverage of this claim. The Plan denied your request. The Plan says the enrollee's condition was not emergent not medically necessary.

Medicare pays for ambulance services only when an emergency exists or when other means of transport would endanger the patient's health. The Plan follows the same rules. 

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 ambulance services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee's presenting symptoms does not meet prudent layperson criteria for emergency care. The documentation does not support that other means of transport were contraindicated. The enrollee did not require expertise services or special equipment that only a fully-equipped ambulance can provide. The ambulance transport on was not medically 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 the ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for the BLS emergency ambulance (A0429) and ground mileage A0425)
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia (J0897).

You asked the Plan to pre-approve Prolia. You say that this is medically necessary. The Plan denied your request. The Plan says this is covered under the enrollee's prescription drug plan.

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 Prolia (J0897).

The Plan has indicated that it has approved Prolia under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Medtronic external infusion pump (E0784) for the
enrollee.

You asked the Plan to pre-approve the pump. You say that this is medically necessary. The Plan denied your
request. The Plan says the records do not support any of the covered indications.

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 pump. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found the requested pump is not Food and Drug Administration (FDA) approved for the requested indication.
here are insufficient studies to show improved long-term outcomes in using the pump to deliver
hydrocortisone. The physician reports that the enrollee has absorption issues with hydrocortisone. There is no
documentation of cortisol levels on hydrocortisone to show that the enrollee needs this pump.

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 pump have not been met. Therefore, we decided that the Plan does not have
to pre-approve a Medtronic external infusion pump (E0784) for the enrollee.