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

We decided that the Plan does not have to pre-approve a second level of vertebral augmentation (22515).
You asked the Plan to pre-approve the second level of vertebral augmentation. You say that you would like reconsideration because this procedure is medically necessary. The Plan denied your request. The Plan says only one level is supported by the records.
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 second level of vertebral augmentation. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found only one level is subacute as documented on the MRI and only one level meets the LCD criteria. 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 second level of vertebral augmentation have not been met. Therefore, we decided that the Plan does not have to pre-approve a second level of vertebral augmentation (22515).
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 medical studies haven't proven that this device is helpful for treatment of the health problem.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 record indicates that the enrollee has lumbar pain with neurogenic claudication. The file contains a secondary report of an MRI stating central spinal stenosis is present. This is not quantified. The MRI report is not submitted for review. The medical records as submitted are not sufficient to demonstrate the medical reasonableness or necessity of the requested service as defined by Medicare rules.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: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve the home ventilator.
You asked the Plan to pre-approve the home ventilator. You say that you have submitted additional testing that
was not present at first level of appeal. You say the device is necessary. The Plan denied your request. The Plan
says that the home ventilation device is not authorized as the provider has not provided evidence the bi-pap is
insufficient for the member per LCD nor provided sufficient information the trilogy is medically necessary.
The Plan follows Medicare rules. Medicare rules say that ventilators may be covered when they are medically
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory
failure due to chronic obstructive pulmonary disease (COPD). The rules also say that the decision to use a
ventilator or a bi-level positive airway pressure device is made based upon the specifics of each person's
medical condition. There must be enough detailed information in the medical record to justify the treatment
selected.
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 home ventilator. Our reviewer says
that the service is medically necessary. Our physician reviewer found the enrollee has a covered condition
found in the Medicare rules. A bi-pap does not offer the best mode of ventilation for the enrollee's conditions.
The documentation in the medical record supports that the ventilator at issue is medically necessary and
reasonable for this patient.
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 home ventilator have been met. Therefore, we decided that the Plan has to
pre-approve the home ventilator..
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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.You asked the Plan to pre-approve SNF care. You say that the enrollee would benefit both mentally and physically with more physical and occupational therapy.The Plan denied your request. The Plan says the stay is not medically necessary.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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. This enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a SNF 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 SNF care have not been met.Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex Superion 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 medical studies have not proven that this device is helpful for treatment of the health problem.
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 Superion device for the enrollee.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve hybrid convergent ablation with AtriClip placement.
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 that the services are not medically necessary.
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 these services. Our reviewer says that the services are medically necessary. Our physician reviewer found the enrollee has persistent and symptomatic atrial fibrillation despite two prior catheter ablation attempts. As he has already tried and failed first line therapies, a hybrid surgical/catheter based approach is recommended as reasonable and appropriate by expert and consensus guidelines and published data if symptoms persist in patients who have failed more conventional catheter based therapies. As he has had prior anticoagulation complication and in addition is on aspirin for concomitant coronary artery disease and atrial clip procedure to obviate the need for anticoagulation is medically reasonable and necessary as well given the plan for a hybrid surgical ablation procedure already. The procedure is reasonable and 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 been met. Therefore, we decided that the Plan has to pre-approve hybrid convergent ablation with AtriClip placement.
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care.

You asked the Plan to pay for acute inpatient hospital care. You say that you would like reconsideration because your doctor feels that you are in need of a 3 day hospital stay following surgery to ensure your safety. The Plan denied your request. The Plan says you have not met the guidelines for coverage of an inpatient hospital admission.

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 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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient care are met in this case.

Our physician reviewer found the record does not indicate the treating physician's reasonable expectation of a length of stay spanning 2 or more midnights. 

We looked at this physician's review, 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. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF services after July 1, 2021.
You asked the Plan to pre-approve the SNF services. You say that you would like reconsideration because the member is slow to recover but the rehabilitation is helping. The Plan denied your request. The Plan says the member does not meet the requirements for approval of SNF 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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the member does 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF services after July 1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean endoskeletalknee-shin fluid swing (L5828), a knee-shin system stance flexion feature (L5845), a knee-shin system fluid stance extension (L5848), an electronic microprocessor control feature (L5856), and an endoskeletal ankle foot system with dorsiflexion and/or plantar flexion control (L5973).You asked the Plan to pre-approveadvanced prosthetic leg services. You say that the requested items are medically necessary to maintain your current activity level.The Plan denied your request. The Plan says there are other items that would meet your needs. The Plan follows Medicare rules. Medicare rules say that the requested prosthetic services require a K3 ambulation level.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 advanced prosthetic leg services. Our reviewer says that the requested prosthetic services are not medically reasonable and necessary. Our physician reviewerfound the advanced leg prosthetic services exceed your medical needs. The documentation notes that the patient uses a cane for balance which is not consistent with a K3 ambulation level. The requested coverage criteria requirethe enrollee be at a K3 ambulation level.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of advanced prosthetic leg services have not been met.Therefore, we decided that the Plan does not have to pre-approvean endoskeletal knee-shin fluid swing (L5828), a knee-shin system stance flexion feature (L5845), a knee-shin system fluid stance extension (L5848), an electronic microprocessor control feature (L5856), and an endoskeletal ankle foot system with dorsiflexion and/or plantar flexion control (L5973).
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 still acute and is going to require clinical recover for twenty-five (25) days minimum.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 enrollee was admitted following an elective incisional hernia repair and developed hypercapneic hypoxic respiratory failure. The record indicates that the enrollee s ventilator dependent. The enrollee continues to receive acute critical care services,and these have not been denied. The medical record does not indicate that the enrollee requires services that the enrollee is not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules 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 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 bone marrow aspiration.
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 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has planned spinal surgery. The use of bone marrow aspiration remains experimental for the use in spinal surgery. More research is needed to show safety and efficacy as a bone graft enhancer or substitute. The bone marrow aspirate 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 bone marrow aspiration.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable controller with harness and electronic connection for a power wheelchair (PWC).
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 covered.
The Plan must follow Medicare rules. Medicare rules say that an expandable controller with harness and electronic connection is covered for PWCs with three power options. We looked at the file and Medicare rules. The file shows that you are able to control the approved power options in the PWC with the included switches and do not need the requested equipment. 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 an expandable controller with harness and electronic connection for a power wheelchair (PWC).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve rhytidectomy of the cheek, chin, and neck (Current Procedural Terminology (CPT) code 15828).

You asked the Plan to pre-approve the services. You say that the service is necessary. The Plan denied your request. The Plan says the requested service/procedure is cosmetic. The Plan states it will not repair a recent accidental injury or improve the function of an abnormal body part.

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 services have not been met. Provider notes that enrollee would like a " face lift" and is "bothered by wrinkles around her mouth and heaviness of her lower face." Provider is requesting a face lift of lower and middle third of the face, rhytidectomy of the cheek, chin, and neck, for this reason. The request is cosmetic and not medically necessary per Medicare guidance as noted below. Therefore, we decided that the Plan does not have to pre-approve rhytidectomy of the cheek, chin, and neck (Current Procedural Terminology (CPT) code 15828).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA).

You asked the Plan to pre-approve radiofrequency ablation (RFA). You say that the requested radiofrequency ablation (RFA) is medically necessary. The Plan denied your request. The Plan says the requested radiofrequency ablation (RFA) 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 radiofrequency ablation (RFA). Our reviewer says that the requested radiofrequency ablation (RFA) is not medically necessary. Our physician reviewer found the enrollee has chronic low back pain. She has had 2 Left SI joint injections and achieved 50% pain relief. She takes Baclofen for spasm. The request is for RFA of the lateral sacral branches. This is considered an experimental/investigational procedure because of the wide variation in efficacy reported in the peer reviewed literature. Therefore, the request is deemed 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 radiofrequency ablation (RFA) have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation (RFA).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia.
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 step therapy requirement is not met.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain
Part B medications.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that
the services are not medically necessary. Our physician reviewer found the enrollee has osteoporosis. She has
not tried and failed the Plan's required drug, zoledronic acid. The records do not show that the required drug
would be contraindicated or less effective; therefore, Prolia 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 Prolia.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy (HIT) services provided on January 14, 2021 billed with code 99601.
You asked the Plan to pay for the HIT services. You say that these were medically necessary services that should be paid. The Plan denied your request. The Plan says these services were billed with an invalid code.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. CPT code 99601 has a status indicator of "I" in the Physician Fee Schedule. This means that it is "invalid for Medicare billing purposes". Based on this information, we decided that Medicare rules for coverage of the HIT services have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion therapy (HIT) services provided on January 14, 2021 billed with code 99601.