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

We decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT code 22869), for the enrollee.
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 Vertiflex device 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 the Vertiflex superion device placement surgery (CPT code 22869), for the enrollee.
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 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 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 are no services at the LTACH that the enrollee requires that are not already available and covered at the current facility. Therefore, this request for LTACH services will be considered not medically necessary at this time. Transfer to a lower level of care may be considered soon when treatment has completed. 

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 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 experimental and investigational services are not covered by Medicare.

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 device 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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device 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 you need IRF care. The Plan denied your request. The Plan says rules for IRF care have 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 enrollee is an 81-year-old male who was admitted to an acute care hospital on April 16, 2021, after a fall. The enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services with 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous positive airway pressure therapy (CPAP)
device.

You asked the Plan to pre-approve a CPAP device. You say that the item is necessary. The Plan denied your
request. The Plan says based on the documentation provided, coverage criteria has not been met.

The Plan follows Medicare rules. Medicare rules say that continued coverage of a PAP device (E0470 or
E0601) beyond the first three months of therapy requires that, no sooner than the 31st day but no later than the
91st day after initiating therapy, the treating practitioner must conduct a clinical re-evaluation and document
that the beneficiary is benefiting from PAP therapy.

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 CPAP device. Our reviewer says that
the item is not medically necessary. Our physician reviewer found the documentation does not support that the
treating practitioner conducted a clinical re-evaluation which documented that the beneficiary was benefiting
from PAP therapy no sooner than the 31st day, but no later than the 91st day, after initiating therapy.

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 CPAP device have not been met. Therefore, we decided that the Plan does not
have to pre-approve a continuous positive airway pressure therapy (CPAP) device.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve neurostimulator.

You asked the Plan to pre-approve neurostimulator. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.

The Plan follows Medicare rules. Medicare rules say that dorsal column stimulators are covered when specific coverage criteria are met. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve neurostimulator. Our reviewer says that the services are not medically necessary. Our physician reviewer found the documentation does not support that the enrollee in this case has a diagnosis that meets the coverage criteria for a spinal cord neurostimulator. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of neurostimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve neurostimulator.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the magnetic resonance imaging (MRI) of upper extremity, right shoulder (73221)

You asked the Plan to pre-approve the MRI of right shoulder. You say that this service is medically necessary. The Plan denied your request. The Plan says an MRI of the right shoulder is not medically necessary and reasonable at this time.

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 of right shoulder. Our reviewer says that the requested MRI is not medically reasonable and necessary. Our physician reviewer found you are a 58-year-old female with bilateral shoulder pain. You had a lipoma removed from the left shoulder. You have a palpable nodule over the left shoulder and a subsequent MRI of the left shoulder has been approved. In this case, there is no specific clinical rationale for the MRI of the right shoulder. There has been no documentation of previous x-rays or previous therapies. The requested MRI is not medically reasonable or 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 of right shoulder have not been met. Therefore, we decided that the Plan does not have to pre-approve the magnetic resonance imaging (MRI) of upper extremity, right shoulder (73221)
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the mandibular partial denture - cast metal framework with resin denture bases (D5214).

You asked the Plan to pre-approve the mandibular partial dentures. You say that you would like the dentures covered. The Plan denied your request. The Plan says coverage for a mandibular partial denture was already provided in June 2018 and therefore you are not covered for another mandibular denture at this time.

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 mandibular partial dentures once every five plan years. 

We looked at the file and Medicare rules. The Plan provided documentation showing mandibular partial dentures were covered by the Plan in June 2018. Based on this information, we decided that the Plan does not have to pre-approve the mandibular partial denture - cast metal framework with resin denture bases (D5214).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the complete mandibular and maxillary dentures (D5510, D5120).

You asked the Plan to pre-approve the complete mandibular and maxillary dentures. You say that you need new dentures. The Plan denied your request. The Plan says you are limited to new dentures once every five years.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items are in excess of those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the complete mandibular and maxillary dentures (D5510, D5120).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gelsyn-3.

You asked the Plan to pre-approve Gelsyn-3. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug does not meet step therapy criteria.

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 Gelsyn-3. Our reviewer says that the documentation does not support that you meet step therapy criteria for the requested drug. Our physician reviewer found you were diagnosed with left knee primary osteoarthritis per radiologic imaging. You have failed conservative measures to treat joint pain. The documentation does not support that you have tried and failed Visco-3, Gel-One, Orthovisc, Synvisc or Synvisc One. There is no documentation provided indicating that the plan's required drugs would likely be less effective and/or likely have adverse effects for you. Therefore, the enrollee does not meet criteria for the requested drug. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Gelsyn-3 have not been met. Therefore, we decided that the Plan does not have to pre-approve Gelsyn-3.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Flexitouch lymphedema pump (with calibrated gradient pressure) and leg garments (CPT code(s): E0652 and E0667), for the enrollee.

You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your request. The Plan says the Medicare rules have not been met.

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 the DME have not been met. Review of the records do not show a trial with a 'basic' pump has been attempted or that the enrollee is unable to attempt a trial with a 'basic' pump. Therefore, we decided that the Plan does not have to pre-approve Flexitouch lymphedema pump (with calibrated gradient pressure) and leg garments (CPT code(s): E0652 and E0667), for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that The Plan denied your request. The Plan says an intensive rehabilitation program is not medically necessary.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for sacral decubitus ulcers. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that this enrollee 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 IRF admission and services.
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 a LTACH admission is medically necessary. The Plan denied your request. The Plan says that based on Medicare guidelines, your request for approval of admission to a LTACH does not meet the requirements for approval.

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 that you were admitted to the current acute care facility with worsening diabetic foot ulcers requiring antibiotics and debridement. Osteomyelitis at first was not seen but later identified in the 5th metatarsal in left foot. Plans are for ongoing antibiotics for a total of approximately 6 weeks with ongoing wound care. You appear to be improving and only require additional short-term acute care services for antibiotics and wound care, which can safely be received at the current facility. You do not require services at the LTACH that are not already available at the current facility. There are no services at the LTACH that you require that are not already available and covered at the current facility. Therefore, this request for LTACH services will be considered not medically necessary at this time. Transfer to a lower level of care may be considered soon when the treatment has completed. 

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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve pantyhose compression stockings (CPT code A6530 X2) and (CPT Code A6545 X2).

You asked the Plan to pre-approve the supplies. You say that you were examined on November 24, 2020, due to bilateral leg pain and were recommended to wear compression stockings in lieu of surgery. You state that you needed eight (8) pairs so that you can wash them by hand once a week minimizing your carpal tunnel pain. The Plan denied your request. The Plan says the provider's office confirmed that you do not have any form of wound on your lower extremities at that time of visit.

We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the supplies have not been met. Review of the records shows that you do not have any form of wound on your lower extremities. Therefore, the supplies are not covered. Furthermore, the rules say the following are examples of wound care items which are non-covered under the surgical dressing benefit because they do not meet the statutory definition of a dressing (not all-inclusive): Gradient compression stockings (A6530). Therefore, we decided that the Plan does not have to pre-approve pantyhose compression stockings (CPT code A6530 X2) and (CPT Code A6545 X2).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot inserts.

You asked the Plan to pre-approve the orthotics. You say that this is medically necessary. 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 foot inserts.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Entyvio 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 a step therapy exception cannot be granted.

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 the drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found in this case, the enrollee has tried and failed Stelara, which is required by the plan. There is no documentation provided indicating that Stelara would likely be less effective and/or likely have adverse effects for 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 drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Entyvio for the enrollee.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pre-approve a sleep study.

You asked the Plan to pre-approve sleep study. You say that you are appealing with supporting records. The Plan denied your request. The Plan says that the denial of authorization for this testing is correct, because the enrollee does not meet the Medicare criteria for this sleep study.

The Plan follows Medicare rules. Medicare rules state that polysomnography testing is covered for the evaluation of obstructive sleep apnea, and different types of sleep testing may be used under different circumstances. 

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 sleep study. Our reviewer says that the enrollee meets the Medicare criteria for the requested sleep study. Our physician reviewer found the enrollee has symptoms such as excessive daytime fatigue, regular snoring, and hypertension to make the diagnosis of obstructive sleep apnea a distinct clinical possibility, which can be best evaluated with a sleep study. Based on the history and examination, the enrollee meets the criteria for this sleep testing, and it is medically reasonable and necessary to assess the enrollee for obstructive sleep apnea. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of sleep study have been met. Therefore, we decided that the Plan has to pre-approve a sleep study.

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.