Persius/hicric huggingface dataset:
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 review indicates that 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 LTACH services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services (CPT 49905) provided to the enrollee on May 15, 2020.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the records do not support the service billed.

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 49905 is "omental flap, to repair defect intra-abdominal (listed 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 the services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our physician reviewer found that in this case, the operative note does not describe the creation of a pedicle omental flap but rather just reinforcement of an anastomosis with a portion of omentum. The elements of CPT code 49905 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 services have not been met. Therefore, we decided that the Plan does not have to pay for surgical services (CPT 49905) provided to the enrollee on May 15, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lumbar-sacral orthosis (L0650) provided on October 5, 2020.
You asked the Plan to pre-approve the lumbar-sacral orthosis. You say that you would like reconsideration because this equipment was medically necessary. The Plan denied your request. The Plan says the member did not receive a video or telephonic visit by the ordering physician in order to warrant the billed codes.
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 lumbar-sacral 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 on an objective physical examination that pain will be reduced by restricting mobility of the trunk. There is no evidence of a recent injury or surgery to the spine that requires the orthosis to facilitate healing. There is no evidence of a deformed spine or weak spinal muscles on an objective physical examination. 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-sacral orthosis have not been met. Therefore, we decided that the Plan does not have to pre-approve lumbar-sacral orthosis (L0650) provided on October 5, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says the care that is being requested is considered custodial, which is non-medical care.
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 the admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse required to safely and effectively provide medically necessary and reasonable treatment in a SNF. There are no complex wound care or other skilled nursing needs. The enrollee's functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist required to safely and effectively provide medically necessary and reasonable treatment in a SNF. Skilled nursing or therapy services are not required on a "daily basis" or as a practical matter on 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 admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Eliquis.

You asked the Plan to pre-approve Eliquis. You say that the enrollee has been stable on this medication. The Plan denied your request. The Plan says this drug is not covered for the enrollee's condition by 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 Eliquis.

Benefits for Eliquis 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 intravenous immune globulin (IVIG) services.

You asked the Plan to pre-approve the requested services. You say that the enrollee has failed high-dose steroids and Rituximab. The Plan denied your request. The Plan says there is lack of medical literature to support the use of IVIG to treat the enrollee's condition or for the requested dosing.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved 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 requested services. Our physician reviewer found that the enrollee has microvasculitis with inability to walk. There is no documentation of chronic demyelinating polyneuropathy. IVIG is only approved for Kawasaki disease and anti-neutrophilic cytoplasmic antibody associated vasculitis. The documentation does not support that the requested services are safe and effective and otherwise reasonable and necessary for this 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 requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve intravenous immune globulin (IVIG) services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve low back surgery lumbar decompression and fusion (CPT code (s): 63056, 20931, 20936, 20930), for the enrollee.
You asked the Plan to pre-approve the services. You say that this is to help treat the sideways curve in the enrollee's lower spine scoliosis, lumbar region. You state this is also to help treat the enrollee's low back pain spinal stenosis. The Plan denied your request. The Plan says the doctor's notes do not show that the enrollee has other factors such as, an instability of their spine or a condition when a bone in their spine slips forward onto the bone below it spondylolisthesis that will require the enrollee to have this surgery. The Plan states the requested surgery is not supported for the condition causing the enrollee's low back pain alone spinal stenosis and due to this, this low back surgery lumbar decompression and fusion 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 items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documented segmental instability of the spine. There is no justification for fusion surgery. There is no severe deformity. There is no significant neurologic deficit requiring lumbar decompression either. 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 low back surgery lumbar decompression and fusion (CPT code (s): 63056, 20931, 20936, 20930), for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for postoperative follow-up visits (99024) provided on October
5, 2020, and November 17, 2020.
You asked the Plan to pay for postoperative follow-up visits. You say that these services should be covered.
The Plan denied your request. The Plan says payment for these services is included in the payment for surgical
services.
The Plan must follow Medicare rules. Medicare rules say that the Medicare approved amount for these
procedures includes payment for services related to the surgery when furnished by the physician who performs
the surgery, such as follow-up visits during the postoperative period of the surgery that are related to recovery
from the surgery.
We looked at the file and Medicare rules. The record shows that the visits at issue are follow-up visits for
surgeries performed on September 2, 2020 and November 11, 2020, that have 90-day postoperative periods of
90 days. These visits are therefore not separately payable. Based on this information, we decided that Medicare
rules for coverage of postoperative follow-up visits have not been met. Therefore, we decided that the Plan
does not have to pay for postoperative follow-up visits (99024) provided on October 5, 2020, and November
17, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve intracept procedure (CPT code(s): C9752 and 22899), for the enrollee.

You asked the Plan to pre-approve the services. You say that the services are medically 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 intracept procedure remains experimental for low back pain. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve intracept procedure (CPT code(s): C9752 and 22899), for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve custom made removable shoe inserts (CPT code L3010).

You asked the Plan to pre-approve foot orthotics. You say that the inserts should be covered due to medical necessity. The Plan denied your request. The Plan says this item is not a covered benefit.

Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. 

Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve custom made removable shoe inserts (CPT code L3010).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ozurdex .1mg injection (CPT code J7312) 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 enrollee does not have advanced glaucoma.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe
and effective and otherwise reasonable and 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 medication. Our physician reviewer
found the records indicate the enrollee has diabetic macular edema and is pseudophakic. The record does not
indicate the enrollee is undergoing cataract surgery. The record does not support any other condition listed in
the Medicare approved compendia. 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 Ozurdex .1mg injection (CPT code J7312) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acupuncture to the enrollee's feet for neuropathy, for the
enrollee.

You asked the Plan to pre-approve acupuncture services. You say that as peripheral neuropathy is difficult to
treat and often requires multiple modalities you are requesting consideration of acupuncture as an adjunct to the
enrollee's treatment. The Plan denied your request. The Plan says this service is not covered for what you are
requesting.

The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we
decided that Medicare rules for coverage of acupuncture services have not been met. The medical records
provided indicate your request is for treatment of neuropathy in the enrollee's feet. This is not a covered service
according to the Medicare rules. Therefore, we decided that the Plan does not have to pre-approve acupuncture
to the enrollee's feet for neuropathy, for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve MRI, spinal canal and contents, lumbar; without
contrast material (CPT code 72148), for the enrollee.
You asked the Plan to pre-approve the MRI. You say that the enrollee needs the MRI of the spine because they
have lower extremity pain with neurological features with or without low back pain. The Plan denied your
request. The Plan says the Medicare rules have not been met.
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 the MRI. Our physician reviewer found
the medical records do not support further evaluation of this enrollee's chronic low back pain with an MRI
lumbar spine at this point. The enrollee has not failed recently implemented conservative therapies and there is
no documentation of any signs or symptoms of a serious underlying condition that would make imaging at this
time 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 MRI have not been met. Therefore, we decided that the Plan does not have
to pre-approve MRI, spinal canal and contents, lumbar; without contrast material (CPT code 72148), 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.
You asked the Plan to pre-approve an MRI. You say that the enrollee has pain persisting for greater than 3 months, and failure of more than 6 weeks of conservative measures. The Plan denied your request. The Plan says the enrollee has not failed six weeks of prescribed treatment.
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 an MRI. Our physician reviewer found that the enrollee presented with complaints of neck, shoulder and low back pain. The medical records only provide one date of service for evaluation of this enrollee's symptoms. It is mentioned that her symptoms are chronic, but the exact timeframe of her symptoms and the specific conservative therapies that had been utilized are not mentioned. There is no indication mentioned for an urgent evaluation that would require an MRI. Therefore, the requested MRI is not medically reasonable and necessary 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 an MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the cervical spine.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit and psychotherapy provided by an out-of-network provider on August 18, 2020.

You asked the Plan to pay for the office visit and psychotherapy. You say that your office went through the steps to obtain prior authorization but was informed it was not required. The Plan denied your request. The Plan says prior authorization was not obtained.

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 had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the office visit and psychotherapy provided by an out-of-network provider on August 18, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the PBRT (CPT code 77523), for the enrollee.

You asked the Plan to pre-approve the PBRT. You say that the enrollee has had thorough discussions regarding
options for treatment and has opted to move forward with proton therapy as definitive treatment for their breast
cancer. The Plan denied your request. The Plan says a review of the literature indicates that PBRT is not the
standard of care for right-sided breast cancer and Proton Beam therapy for primary treatment of breast cancer is
not supported.

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 PBRT. care. Intensity-modulated
radiation therapy (IMRT) that is photon based is designed to facilitate normal tissue sparing and could very
readily be considered in this patient. While proton therapy can be used (and is often used for select patients
with unique anatomic considerations) the case file does not provide a plausible rationale for the need of proton
therapy over conventional radiation and/or IMRT in this enrollee. Furthermore, the LCD does not include right
sided breast cancer as a Group 1 or Group 2 indication.

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 PBRT have not been met. Therefore, we decided that the Plan does not have
to pre-approve the PBRT (CPT code 77523), for the enrollee.