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

We decided that the Plan does not have to pre-approve an implantable neurostimulator electrode.

You asked the Plan to pre-approve spinal cord stimulator. You say that the enrollee has failed other treatment methods, and this offers a non-opioid solution to the enrollee's chronic and debilitating pain. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because the enrollee does not have an indication for which this is covered.

The Plan follows Medicare rules. Medicare rules state that spinal cord stimulation may be covered under certain specific clinical indications. 

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 spinal cord stimulator. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested nerve stimulator. Our physician reviewer found the enrollee does not have a covered indication for peripheral nerve stimulation. This request 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 spinal cord stimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve an implantable neurostimulator electrode.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Superion interspinous spacer (Vertiflex device).

You asked the Plan to pre-approve the Vertiflex device Superion interspinous spacer. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested 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 the Vertiflex device Superion interspinous spacer. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found you have back pain. The spacer device remains experimental. More research is needed to show safety and efficacy of the vertiflex spacer device. Open laminectomy surgery is the gold standard for lumbar decompression. Therefore, you do not meet criteria for the requested services. 

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 Vertiflex device Superion interspinous spacer have not been met. Therefore, we decided that the Plan does not have to pre-approve Superion interspinous spacer (Vertiflex device).
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a Positron Emission Tomography (PET) scan (78815).

You asked the Plan to pre-approve a PET. You say that this is medically necessary. The Plan denied your request. The Plan says that only 3 PET scans are supported.

The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are medically necessary.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a PET. Our reviewer says that the requested PET scan is medically necessary in this case. Our physician reviewer found PET scans are indicated to determine staging of disease that impacts treatment decision making. This patient has a new mass on magnetic resonance imaging for which palliative therapy is being considered for her metastatic cervical cancer. Her last PET scan was in 2018.

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 PET have been met. Therefore, we decided that the Plan has to pre-approve a Positron Emission Tomography (PET) scan (78815).

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 pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that the enrollee is too weak to go home. The Plan denied your request. The Plan says the services are 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 medically necessary. Our physician reviewer found the enrollee was admitted to the hospital for acute respiratory failure, pneumonia, and pleural effusion. His medical problems are stable and there are no complex nursing or rehabilitation needs. He 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. There is not a reasonable expectation that the 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that an IRF admission is medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of an IRF admission.

The Plan must follow Medicare rules. The rules say that an 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 patient'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 non-operative management of a pelvic fracture after a fall. Her medical problems are stable. There are no complex nursing or rehabilitation needs.

The patient 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.

Additionally, 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 an acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the treatment of root canal obstruction (D3331) provided on June 29, 2020.
You asked the Plan to pay for the treatment of root canal obstruction. You say that this service should have been covered. The Plan denied your request. The Plan says this service is not covered. The Plan also says that you were advised during your call with the Plan on June 26, 2020 that treatment of root canal obstruction (D3331) was not a covered procedure under your dental benefits.
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 or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the treatment of root canal obstruction (D3331) provided on June 29, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex Superion interspinous spacer device.

You asked the Plan to pre-approve a Vertiflex Superion interspinous spacer device. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested 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 a Vertiflex Superion interspinous spacer device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has chronic low back pain due to lumbar spinal stenosis with neurogenic claudication. The spacer device remains experimental. More research is needed to show safety and efficacy of the device. Open laminectomy surgery is the gold standard procedure. Therefore, the enrollee does not meet criteria for the requested services.

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 Vertiflex Superion interspinous spacer device have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex Superion interspinous spacer device.
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 you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested admission 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's condition remains serious. The enrollee was still positive for COVID-19 and was considered infectious. The documentation does not support that the enrollee requires services at the LTACH that are not available at the acute care hospital where the enrollee is 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.

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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a white glass with high gold content crown (D2750) for tooth #10.
You asked the Plan to pre-approve the crown. You say that this is medically necessary. The Plan denied your request. The Plan says the x-rays from the dentist do not show that this service is medically necessary.
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 the crown when the services are medically necessary and reasonable. 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 crown. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found the enrollee presents with a request for a crown on tooth #10 that had been approved for endodontic treatment and a support post. The tooth has existing distal decay, with no other damage to other surfaces. In this instance, there is less than 50% of the structure missing from decay or fracture. The integrity of the tooth is good, and there has been approval for a support post following the endodontic treatment. The decayed area of the tooth may be filled during the post process or by a two or three surface composite restoration. Given the overall condition of the anterior tooth following endodontic treatment, a crown would not be considered necessary as a lesser means of restoration is possible.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the crown have not been met. Therefore, we decided that the Plan does not have to pre-approve a white glass with high gold content crown (D2750) for tooth #10.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the prolonged evaluation and management service.

You asked the Plan to pay for prolonged evaluation and management service. You say that the Plan should pay
this claim. The Plan denied your request. The Plan says the documentation does not indicate that the provider
ever performed a face-to-face for the enrollee.

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 99358 is Prolonged evaluation and management service
before and/or after direct patient care; first hour.

We find that CPT code 99358 is not supported in the medical record. Specifically, the medical records do not
show a direct contact with the patient was made before or after the service. Based on this information, we
decided that Medicare rules for coverage of prolonged evaluation and management service have not been met.
Therefore, we decided that the Plan does not have to pay for the prolonged evaluation and management service.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Jazzy Air 2 with an elevating seat lift (K0899).

You asked the Plan to pre-approve Jazzy Air 2 with an elevating seat lift. You say that the item is medically necessary. The Plan denied your request. The Plan says the item requested does not meet the definition of a specific POV/PWC, and therefore, is not medically necessary and reasonable.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.

We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Jazzy Air 2 with an elevating seat lift have not been met. Specifically, the item requested does not meet the definition of a POV/PWC and must be denied as not reasonable or necessary. Therefore, we decided that the Plan does not have to pre-approve Jazzy Air 2 with an elevating seat lift (K0899).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an electrocardiogram provided on August 6, 2020.
You asked the Plan to pay for the electrocardiogram. The Plan denied your request. The Plan says there was not a valid authorization for these services.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the electrocardiogram. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for an electrocardiogram provided on August 6, 2020.
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 would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested admission 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 the enrollee's medical problems are stable. The documentation does not support that the enrollee requires an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not support that the enrollee requires an intensive rehabilitation therapy program. 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 24 additional physical therapy visits.
You asked the Plan to pre-approve 24 additional physical therapy visits. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee's needs can be met with a home exercise program.
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 24 additional physical therapy visits. 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 the patient's condition beyond what was approved by the health plan. The patient has had instructed in a home exercise program and her deficits do not require ongoing skilled therapy. The records do not demonstrate that the patient's functional status needs the unique skills of a professional therapist to safely and effectively provide treatment or a maintenance 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 24 additional physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 24 additional physical therapy visits.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).

You asked the Plan to pre-approve SNF admission. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are 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 admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have documented skilled therapy needs. The enrollee is consistently ambulating more than 100 feet and tending to activities of daily living with minimal supervision. The documentation does not support that the enrollee requires the specialized skill, knowledge and judgment of a qualified professional nurse or qualified therapist to safely and effectively provide medically necessary and reasonable treatment. As a practical matter, the enrollee's care needs can be provided 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 SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve routine eyewear (eyeglasses).
You asked the Plan to pre-approve eyeglasses. You say that you would like these glasses covered by the Plan. The Plan denied your request. The Plan says the service you are requesting has been exhausted.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers frames and lenses for routine eyeglasses once every 2 years. We looked at the file and the Plan's rules. The file indicates that you last received lenses and frames that were covered by the Plan in August 2020. Based on this information, we decided that the Plan's rules for coverage of eyeglasses have not been met as your benefit has been exhausted. Therefore, we decided that the Plan does not have to pre-approve routine eyewear (eyeglasses).