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

We decided that the Plan does not have to pay for the laboratory services rendered on September 21, 2020.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says there is no valid physician order.

The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a physician who has furnished a consultation or treats an enrollee for a specific medical problem. 

The file does not contain documentation of an established relationship between the enrollee and the ordering provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this testing have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on September 21, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient hospital care for the approved surgery.

You asked the Plan to pre-approve inpatient hospital care for the approved surgery. You say that the requested inpatient hospital care for the approved surgery is medically necessary. The Plan denied your request. The Plan says the requested inpatient hospital care for the approved surgery 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 inpatient hospital care for the approved surgery. Our reviewer says that the requested inpatient hospital care for the approved surgery is not medically necessary. Our physician reviewer found the enrollee is undergoing a shoulder arthroplasty. The provided medical records do not document any conditions that would result in the enrollee's medical condition, safety, or health being significantly and directly threatened if care was provided in a less intensive setting. The elements of the coverage criteria are not satisfied. The requested service cannot be recommended. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient hospital care for the approved surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient hospital care for the approved surgery.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nutria-pharmaceutical injections and treatment with a Sanexas device reported on August 19, 2020.

You asked the Plan to pay for the nutria-pharmaceutical injections and treatment with a Sanexas device. You say that the treatment was medically necessary and should be covered. The Plan denied your request. The Plan says the record does not support that the procedures were performed as 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 HCPCS/CPT Code Manual definition of code 97016 is application of blood vessel compression or decompression device to 1 or more areas. The HCPCS/CPT Code Manual definition of code 97032 is application of a modality to 1 or more areas; electrical stimulation (manual), each 15 minutes. The HCPCS/CPT Code Manual definition of code 97150 is therapeutic procedure(s), group (2 or more individuals). The HCPCS/CPT Code Manual definition of code 96372 is therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular. The HCPCS/CPT Code Manual definition of code J3490 is unclassified drug injection. The HCPCS/CPT Code Manual definition of code J3411 is injection, thiamine hcl, 100 mg. The HCPCS/CPT Code Manual definition of code J3415 is injection, pyridoxine hcl, 100 mg. 

We find that HCPCS/CPT codes 97016, 97032, and 97150 are not supported in the medical record. Specifically, the record does not support that a blood vessel compression device was applied. The manufacturer of the Sanexas device describes it as an electric cell signaling energy wave device, which does not meet the criteria to report CPT code 97016. The record also does not support that manual electrical stimulation was applied to any area for any amount of time. The record states that the Sanexas device was applied using standard programs. This does not support constant direct patient contact, which is required to report CPT code 97032. The record also does not support that therapeutic procedures in a group of 2 or more was performed. The record does not mention any therapeutic procedures, or the presence of any other patients receiving therapy at the same time; the criteria for reporting CPT code 97150 has not been met. 

Payment for HCPCS/CPT codes 96372, J3490, J3411, and J3415 are not supported. Specifically, the record does not contain documentation of the dosage and type of drug administered in each injection, which is required by Medicare for these services to be reimbursed. 

Based on this information, we decided that Medicare rules for coverage of the nutria-pharmaceutical injections and treatment with a Sanexas device have not been met. Therefore, we decided that the Plan does not have to pay for the nutria-pharmaceutical injections and treatment with a Sanexas device reported on August 19, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Crestor tablets.

You asked the Plan to pre-approve Crestor tablets. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says Crestor tablets are not covered under your Medicare Part B benefit.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Crestor tablets.

Benefits for Crestor tablets may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex device.

You asked the Plan to pre-approve a Vertiflex device. You say that the requested Vertiflex device is medically
necessary. The Plan denied your request. The Plan says the requested Vertiflex device 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 a Vertiflex device. Our reviewer says
that the requested Vertiflex device is not medically necessary. Our physician reviewer found the enrollee is
diagnosed with spinal stenosis. The Vertiflex device remains experimental for the treatment of back pain. More
research is needed to show safety and efficacy of the Vertiflex 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 a Vertiflex device have not been met. Therefore, we decided that the Plan does
not have to pre-approve a Vertiflex device.
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 IRF care is medically necessary. The Plan denied your request. The Plan says the records do not show that the enrollee requires an intense rehab program at an inpatient rehab facility. The Plan says that the enrollee can receive the care needed at another level of care, such as outpatient therapy.

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 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 enrollee has a past medical history of diabetes and below the knee amputation and is living at home with weakness and trouble ambulating. The enrollee's medical conditions 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. The enrollee does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services 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 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 porcelain fused to high metal crown rendered on January
6, 2021.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the services are not covered.

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
porcelain fused to high metal crown rendered on January 6, 2021.
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 requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH 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 admission to a LTACH is not medically necessary. Our physician reviewer found the progress notes show that the enrollee appears to be improving but requires additional short-term acute care services which can be safely administered at the current facility until a lower level of care is appropriate. The enrollee does not require services at the LTACH that are not already available at the current facility. There are no services at the LTACH that the enrollee requires that are not already covered and available at the current facility. Therefore, this request for LTACH services will be considered not 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 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: 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 requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH 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 admission to a LTACH is not medically necessary. Our physician reviewer found the enrollee, with a history of non-Hodgkin's lymphoma, was admitted due to sepsis with acute kidney injury and organ dysfunction. The enrollee still has a chest tube in place and is receiving intravenous antibiotics. The enrollee continues to receive acute care services that have not been denied. The medical records provided do not indicate that the enrollee requires acute care services that he is not currently receiving that would be available at the LTACH. 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Enbrel Sureclick.

You asked the Plan to pre-approve Enbrel Sureclick. You say that Enbrel helps the enrollee to control her psoriatic arthritis. The Plan denied your request. The Plan says this medication does not fall under Part B.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Enbrel Sureclick.

Benefits for Enbrel Sureclick may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: 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 requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH 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 admission to a LTACH is not medically necessary. Our physician reviewer found the enrollee was admitted due to hypoxia due to COVID-19 pneumonia. The enrollee is not clinically stable as he has ongoing hypoxia and agitation following stroke. The enrollee continues to receive acute care services that have not been denied. The medical records provided do not indicate that the enrollee requires acute care services that he is not currently receiving that would be available at the LTACH. 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 annulus repair device (represented by Barricaid) with the approved L5-S1 Microdiscectomy procedure.

You asked the Plan to pre-approve annulus repair device (represented by Barricaid) with the approved L5-S1 Microdiscectomy procedure. You say that the requested annulus repair device (represented by Barricaid) with the approved L5-S1 Microdiscectomy procedure is medically necessary. The Plan denied your request. The Plan says the requested annulus repair device (represented by Barricaid) with the approved L5-S1 Microdiscectomy procedure 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 annulus repair device (represented by Barricaid) with the approved L5-S1 Microdiscectomy procedure.

Our reviewer says that the requested annulus repair device (represented by Barricaid) with the approved L5-S1 Microdiscectomy procedure is not medically necessary. Our physician reviewer found the enrollee is with chronic low back pain with right-sided radiculopathy affecting function who has tried and failed conservative measures. The Plan approved outpatient L5-S1 Microdiscectomy. The Barricade annulus repair device remains 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 annulus repair device (represented by Barricaid) with the approved L5-S1 Microdiscectomy procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve annulus repair device (represented by Barricaid) with the approved L5-S1 Microdiscectomy procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 3, multiple power option power wheelchair (K0861), and accessories.

You asked the Plan to pre-approve a Group 3, multiple power option power wheelchair, and accessories. You say that the enrollee needs a Group 3 power wheelchair with power tilt and recline seating system. The Plan denied your request. The Plan says the enrollee does not meet criteria for tilt and recline features and therefore does not meet criteria for the requested base code power wheelchair.

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 Group 3, multiple power option power wheelchair, and accessories. Our reviewer says that the requested tilt and recline option is not considered medically reasonable and necessary in this case. Our physician reviewer found the patient does not use a ventilator mounted to the wheelchair and does not meet coverage criteria for a power tilt and power recline seating system. There is no evidence of intermittent catheterization, spasticity, or evidence of being high risk for a pressure ulcer on the medical provider progress notes. The patient is able to stand step transfer, has intact skin, no documented prior pressure ulcer. The tone is noted as normal. The tilt and recline and power options are not medically necessary. 

We looked at this physician's review, the file, and Medicare rules. The power tilt and recline seating system is not medically necessary. Based on this information, we decided that Medicare rules for coverage of a Group 3, multiple power option power wheelchair, and accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 3, multiple power option power wheelchair (K0861), and accessories.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aids provided on September 14, 2020.

You asked the Plan to pay for the hearing aids. The Plan denied your request. The Plan says that the Plan paid the hearing aid benefit amount of $2,000.

Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. 

We looked at the file and the Plan's rules. The file shows that the Plan paid $2,000, which is the maximum allowance for hearing aid coverage under your Plan. Therefore, we decided that the Plan does not have to pay an additional amount for hearing aids provided on September 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a partial upper denture (D5213) and partial lower
denture (D5214).

You asked the Plan to pre-approve the dentures. You say that these dentures are necessary. The Plan denied
your request. The Plan says your supplemental dental benefit does not cover dentures.

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 pre-approve a
partial upper denture (D5213) and partial lower denture (D5214).