Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the MyoPro Motion G Orthotic device (CPT code L8702), for the enrollee.

You asked the Plan to pre-approve the device. You say that the device is necessary. The Plan denied your request. The Plan says your request is not medically necessary because this device has deluxe features that exceed the enrollee's needs and replaces, rather than improves the function of the enrollee's arm.

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 items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this device is contraindicated for those with rigid spasticity such as in this case. Therefore, this request for MyoPro Motion G Orthotic device will be considered not medically necessary or reasonable. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the device have not been met. Therefore, we decided that the Plan does not have to pre-approve the MyoPro Motion G Orthotic device (CPT code L8702), for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional physical therapy visits.

You asked the Plan to pre-approve physical therapy. You say that you feel it is necessary to have physical therapy because of the amount of pain you are in. The Plan denied your request. The Plan says the denial of authorization for additional therapy is correct, because you are able to do home exercises and do not need continued physical therapist services.

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 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 physical therapy. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the additional requested therapy is not generally accepted as specific and effective therapy for your condition, beyond what the Plan has already approved. You have had extensive prior therapy and the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effective performed only by a therapy, or - for physical therapy - under the supervision of a therapist. You have been instructed in a home exercise program. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of physical therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve additional physical therapy visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve durable medical equipment to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve durable medical equipment. You say that you would like this approved. The Plan denied your request. The Plan says there are in-network providers available.

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 durable medical equipment 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 the shoulder arthroscopy (29823) provided on September 9, 2020.

You asked the Plan to pay for the shoulder arthroscopy. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does 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 29823 is arthroscopy, shoulder, surgical; debridement, extensive. 

We asked our coder 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 shoulder arthroscopy. Our reviewer says that CPT code 29823 does not meet criteria for billing or reimbursement consideration. Our reviewer found The medical records provided do not include sufficient documentation to validate that an arthroscopy, shoulder, surgical; debridement, extensive, 3 or more discrete structures was performed on September 9, 2020, therefore this service cannot be verified. 

We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the shoulder arthroscopy have not been met. Therefore, we decided that the Plan does not have to pay for the shoulder arthroscopy (29823) provided on September 9, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve rehabilitation services at an outpatient rehabilitation day institute program.

You asked the Plan to pre-approve outpatient rehabilitation day institute program. You say that you have not yet healed and are unable to get up and walk. The Plan denied your request. The Plan says the denial of authorization for an outpatient rehabilitation day institute program is correct, because this is not medically necessary, and your needs can be met in a standard outpatient rehabilitation setting.

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 outpatient rehabilitation day institute program. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found based on the records provided it is unclear what additional services would be provided by the outpatient rehabilitation day institute program as opposed to a traditional outpatient physical therapy treatment plan. The prescribing provider has ordered physical therapy twice weekly for six weeks. If the outpatient rehabilitation day institute program comprises additional services beyond physical therapy twice weekly for six weeks then it is 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 outpatient rehabilitation day institute program have not been met. Therefore, we decided that the Plan does not have to pre-approve rehabilitation services at an outpatient rehabilitation day institute program.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional physical therapy visits.

You asked the Plan to pre-approve physical therapy. You say that you have ongoing neck pain and feel that this is necessary. The Plan denied your request. The Plan says the requested additional therapy visits are not medically necessary. The Plan also says that they have approved authorization for 2 additional visits, so this denial is only for 8 additional visits beyond what the Plan approved.

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 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 physical therapy. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found there is no documentation that the requested additional therapy is generally accepted as specific and effective therapy for your condition. You appear to have plateaued or even worsened with therapy. Further skilled therapy at this point does not appear to be likely to achieve any significant improvement in your symptoms or functional status. Follow-up with your treating provider for re-evaluation of your condition and/or transition to a home exercise program appears appropriate at this point. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of physical therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve additional physical therapy visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the office visits and services (CPT code(s): 99204, 92136, 92025, and 92134) for the enrollee to be provided by a tertiary level Ophthalmologist.

You asked the Plan to pre-approve the office visits and services. You say that the enrollee went to a provider and were told the enrollee's surgery would cost $3000, but the enrollee went to the tertiary specialist and were told the providers there would do the surgery at no cost. The Plan denied your request. The Plan says there is no medical necessity for care at a highly specialized facility.

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 provider at issue in this case is not a network provider with the Plan. 

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 office visits and services. Our physician reviewer found the record does not indicate a medical reason for the tertiary level referral. The record indicates that the referral is based on patient preference. The elements of the coverage determination 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 office visits and services have not been met.

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 the office visits and services. Therefore, we decided that the Plan does not have to pre-approve the office visits and services (CPT code(s): 99204, 92136, 92025, and 92134) for the enrollee to be provided by a tertiary level Ophthalmologist.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.

You asked the Plan to pre-approve foot orthotics. You say that your right foot is susceptible to pain and swelling without orthotics. 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 orthotics.
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 it is felt that your needs warrant the level of care at the IRF. The Plan denied your request. The Plan says your needs are medically stable and medical complexity of your conditions is low. You do not require frequent physician supervision for ongoing management of your medical conditions during your rehabilitation stay.

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 patient was admitted for a pneumothorax after an image-guided lung biopsy. Medical problems are stable. There are no complex nursing or rehabilitation needs. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an ultralightweight wheelchair to be provided by the requested provider.
You asked the Plan to pre-approve the ultralightweight wheelchair. The Plan denied your request. The Plan says the enrollee does not have out-of-network benefits unless prior authorization is granted.
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 item at issue in this appeal. We found no exception that would require the Plan to pre-approve this item. Therefore, we decided that the Plan does not have to pre-approve an ultralightweight wheelchair to be provided by the requested provider.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve Freestyle Libre 14-Day Sensor, for the enrollee.
You asked the Plan to pre-approve the sensor. You say that the sensor is necessary. The Plan denied your request. The Plan says that the enrollee is taking a fixed dose of insulin and do not adjust doses based on the enrollee's blood sugar readings. The Plan states a continuous glucose monitor (CGM) is not covered in the enrollee's individual medical circumstances according to Medicare rules. The Plan states Medicare only covers a CGM to help individuals who are intensely managing their diabetes. The Plan states this requires use of an insulin pump or insulin injections at least three times with adjustments based on four times a day blood glucose testing.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered reasonable and necessary for enrollees with diabetes who meet criteria referenced 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 the sensor. Our physician reviewer found although there is no sliding scale listed, there is little blood glucose (BG) data and the a1c is far from goal, so it seems like the nurse practitioner is trying to get the enrollee to take their insulin shots and then use BG data to adjust the doses. The enrollee does meet the criteria and would benefit from it. 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 sensor have been met. Therefore, we decided that the Plan has to pre-approve Freestyle Libre 14-Day Sensor, for the enrollee.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve a periodontist visit to be rendered by an OON provider.
You asked the Plan to pre-approve the periodontist visit. You say that you would like to see this provider because he is close to your home. The Plan denied your request. The Plan says that the documentation indicates that your needs can be met in-network, and going OON is not medically necessary at this time. The Plan also says that there are no participating periodontists within 20 miles of you.
The Plan must follow Medicare rules. Medicare rules say that plans are required to arrange for OON care when network providers are inadequate or inaccessible. The rules also require plans to forward sufficient information to the IRE. We looked at the file and Medicare rules. The Plan sent additional information stating that there are no participating periodontists within 20 miles of your residence. Based on this information, we decided that Medicare rules for coverage of the periodontist visit have been met. Therefore, we decided that the Plan has to pre-approve a periodontist visit to be rendered by an OON provider.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve the ClariFix procedure (CPT code 31237 and 30117), for the enrollee.
You asked the Plan to pre-approve the ClariFix procedure. You say that the enrollee wakes up in the middle of night and only gets a few hours of sleep due to their postnasal drip. The Plan denied your request. The Plan says that the services are considered experimental and investigational.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the ClariFix procedure. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has a clear diagnosis of rhinitis. The enrollee has the symptoms of rhinitis and responded appropriately to medical management (temporary relief). The enrollee would benefit from a surgical procedure of the vidian nerve to reduce his symptoms and help manage his condition. Until recently vidian neurectomy was the only procedure available. However, it requires general anesthesia, and has complications such as dry eye. Now a minimally invasive approach is available that can be performed in the office. The evidence is limited because this is a new device. However, the evidence behind addressing the vidian nerve is well established and procedures to address this nerve have been done since the 1960's. Ablating the vidian nerve is not experimental and is actually considered the standard of care for surgical treatment of rhinitis. How the ablation is done should be determined by the surgeon performing the procedure. The clarifix device ablates the nerve via cryotherapy, instead of using sharp instruments to cut the nerve permanently like in a vidian neurectomy. The goal of the procedure is the same - to reduce rhinitis by addressing the underlying nerve that contributes to nasal drainage. 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 ClariFix procedure have been met. Therefore, we decided that the Plan has to pre-approve the ClariFix procedure (CPT code 31237 and 30117), for the enrollee.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve oral device/appliance (CPT code E0486), for the enrollee.
You asked the Plan to pre-approve the device. You say that the device is necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for an oral device/appliance. The Plan states the enrollee is able to tolerate a positive airway pressure (PAP) device and their physician clearly documents within the enrollee's medical record that the enrollee 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 the device. Our physician reviewer found the coverage criteria for a mandibular advancement device (MAD) are not met. This enrollee has severe OSA with AHI greater than 30, and is doing well on BiPAP. The enrollee is requesting an MAD for travel. Medicare does not cover an MAD for OSA with AHI greater than 30, unless there is PAP intolerance. Further, Medicare does not cover durable medical equipment (DME) specifically for travel, which is considered a convenience. A MAD is considered not medically necessary, and the denial is upheld. 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 has not been met. Therefore, we decided that the Plan does not have to pre-approve oral device/appliance (CPT code E0486), for the enrollee.