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

We decided that the Plan does not have to pre-approve CT, thorax, diagnostic; without contrast material (CPT code 71250).
You asked the Plan to pre-approve the CT scan. You say that the CT scan from December 2020 is showing growth on the lung and denying this request for a follow up scan is detrimental. The Plan denied your request. The Plan says the service is not necessary.
The Plan must follow Medicare rules. Medicare rules say that CT 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 the CT scan. Our physician reviewer found there is no specific clinical rationale for the requested CT scan. There was no documentation provided on the previous Lung CT despite request. The review has determined that the requested CT Scan is not medically reasonable or necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve CT, thorax, diagnostic; without contrast material (CPT code 71250).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hyalgan.
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 knee pain. She has not tried and failed the Plan's required drugs, Orthovisc and Monovisc. The records do not show that the required drugs would be contraindicated or less effective; therefore, Hyalgan 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 Hyalgan.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for outpatient rehabilitation services provided from January 18, 2021, to March 1, 2021.
You asked the Plan to waive the copayments for outpatient rehabilitation services. You say that you should only owe a $40 copayment and feel that you should not be responsible for the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment for outpatient rehabilitation services.
You received outpatient rehabilitation services from January 18, 2021, to March 1, 2021, for a total of 8 visits. Therefore, you are responsible to pay a $40 copayment per each visit. The total amount you owe is: $40 (copayment) x 8 (outpatient rehabilitation visits) = $320. You have been asked to pay the total copayment amount of $320 for outpatient rehabilitation services. Outpatient rehabilitation services fall within the outpatient rehabilitation services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for outpatient rehabilitation services provided from January 18, 2021, to March 1, 2021.
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 services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that 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 you do not require skilled nursing or therapy services on a daily basis. You do 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 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: 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 IRF services are medically necessary because the enrollee is significantly de-conditioned compared to baseline. The Plan denied your request. The Plan says IRF is not medically necessary. The enrollee may be able to have care at a lower level like a skilled nursing facility.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve neuropsychological testing.
You asked the Plan to pre-approve neuropsychological testing. The Plan denied your request. The Plan says this 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 neuropsychological testing. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that it was noted that this enrollee's provider is asking for this procedure to be used to assess this enrollee's cognitive performance to determine his range of function. The enrollee had an evaluation of memory based on clinical interview showing low normal, fluency in the mildly impaired range, with 17/29 on the memory orientation screening test and 21/30 on the Folstein Mini mental status exam. Based review of the information provided, this enrollee does not meet the criteria for neuropsychological testing as his cognitive evaluation had been evaluated clearly, and the use daily of marijuana interferes with the accuracy despite having been sober for one month.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of neuropsychological testing have not been met. Therefore, we decided that the Plan does not have to pre-approve neuropsychological testing.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex Superion device.

You asked the Plan to pre-approve a Vertiflex Superion device. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.

The Plan 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 device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the vertiflex device is experimental. More research is needed to show safety and efficacy of the device.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a Vertiflex Superion device have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex Superion device.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Retacrit.
You asked the Plan to pre-approve Retacrit. You say that the requested drug is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage have not been met.
The Plan follows Medicare rules. Medicare rules say that Retacrit is only covered for certain 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 Retacrit. Our reviewer says that the requested drug is not medically reasonable and necessary. Our physician reviewer found that the enrollee is a 73-year-old man whose provider has requested Retacrit to treat anemia. The member does not have a definitive diagnosis of myelodysplastic syndrome (MDS). The accepted use of this drug requires a confirmed diagnosis of MDS with a bone marrow biopsy, the anemia is symptomatic, there is reasonable expectancy of longer survival, and therapy will end or reduce the need for transfusions. The review has determined that the enrollee does not have a covered indication for Retacrit. The enrollee does not have a definitive diagnosis of myelodysplastic syndrome. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Retacrit have not been met. Therefore, we decided that the Plan does not have to pre-approve Retacrit.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Comprehensive Genomic Profiling (CGP) testing provided on September 14, 2020.

You asked the Plan to pay for the CGP testing. The Plan denied your request. The Plan says this is not a covered service.

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 pay for the CGP testing. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee is a 67-year-old male with hypertension, hyperlipidemia, atherosclerosis, and long-term use of antithrombotics/antiplatelets. The prescribing physician tested for more medications than were to be seriously considered for this enrollee and so this was not a targeted panel. This panel was not supported as being medically necessary in the documentation provided as it was too comprehensive and included unnecessary tests.

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 CGP testing have not been met. Therefore, we decided that the Plan does not have to pay for the Comprehensive Genomic Profiling (CGP) testing provided on September 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor.
You asked the Plan to pre-approve a therapeutic continuous glucose monitor. You say that you believe that it is medically necessary for the enrollee to have this device. The Plan denied your request. The Plan says the criteria for a therapeutic continuous glucose monitor have not been met.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a therapeutic continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve wheelchair accessories.
You asked the Plan to pre-approve the requested items. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that wheelchair accessories are only covered under certain medical indications.
The file shows that gel arm pads, elbow pads, and waffle support pads were requested. We looked at the file and the rules. These items were requested for added convenience, and do not meet the reasonableness test. Based on this information, we decided that the Medicare rules for coverage have not been met.
The file shows that a driving platform for a joystick, nucleus mount, and ultralight mechanical switch were requested. We looked at the file and the rules. A harness (E2313) describes all of the wires, fuse boxes, fuses, circuits, switches, etc. that are required for the operation of an expandable controller. It also includes all the necessary fasteners, connectors, and mounting hardware. The requested items cannot be separately requested. Based on this information, we decided that the Medicare rules for coverage have not been met.
The file shows that a Maxx Cane mount height and flip back were requested. We looked at the file and the rules. These items are included in the power tilt and recline seating system. These items are not able to be requested separately. Based on this information, we decided the Medicare rules for coverage have not been met.
The file shows that a foot and ankle positioner were requested with CPT code K0108. We looked at the file and the rules. Medicare rules say that providers must report services correctly. We find that the CPT code for the requested item has not been coded correctly. Based on this information, we decided that the rule for coverage have not been met.
The file shows that a mount for back interface were requested. We looked at the file and the rules. There is no separate payment for mounting hardware for a seat or back cushion. Based on this information, we decided that the Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pre-approve the requested wheelchair accessories.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lipectomy (15836).

You asked the Plan to pre-approve the lipectomy. You say that the procedure is medically necessary. The Plan denied your request. The Plan says the procedure is cosmetic in nature and not covered.

The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are coverable.

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 lipectomy. Our reviewer says that the lipectomy is not medically necessary. Our reviewer found the record indicates the enrollee had massive weight loss following bariatric surgery. A note from April 2021 indicates there is no evidence of rash. The medical records provided are insufficient to establish the medical reasonableness or necessity of the requested procedure.

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 lipectomy have not been met. Therefore, we decided that the Plan does not have to pre-approve a lipectomy (15836).
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 your needs cannot be met at a lower level of care. You say that your potential to return to the community is extremely likely due to the devotion of your supportive family. The Plan denied your request. The Plan says the medical necessity criteria have not been met.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.
Our physician reviewer found the 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 was admitted for a craniotomy for clipping of a cerebral aneurysm. 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lumbar facet joint injections.
You asked the Plan to pre-approve the injections. The Plan denied your request. The Plan says this is not medically necessary.
The Plan follows Medicare rules. Medicare rules say that facet joint injections are covered for the indications established in the applicable LCD. 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 injections. Our reviewer says that the requested injections are not medically reasonable and necessary. Our physician reviewer found that the medical record indicates that the enrollee has low back pain with primarily radicular symptoms to the left leg and foot. Imaging shows degenerative changes with foraminal narrowing. The enrollee has untreated radiculopathy that is the primary complaint. The elements of the coverage determination are not satisfied. 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 injections have not been met. Therefore, we decided that the Plan does not have to pre-approve lumbar facet joint injections.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pay for therapeutic procedure, on one or more areas, each lasting 15 minutes (97110) provided January 20, 2021.
You asked the Plan to pay for the therapeutic services. You say that many of the requested services in 2020 are not available on an outpatient basis secondary to the recent COVID19 Virus pandemic. Please review all attached documentation supporting this request and process the claim for payment. The Plan denied your request. The Plan says the records do not support the billed service.
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 97110 is therapeutic procedure, on one or more areas, each lasting 15 minutes. We find that CPT code 97110 is not supported in the medical record. Specifically, the records indicate that the service is performed by a physical therapist assistant in a home or hospice setting. There is an appropriate HCPCS code (G0157) for the billed service. The plan made multiple attempts to obtain the additional information from the provider without success. Based on this information, we decided that Medicare rules for coverage of the therapeutic services have not been met. Therefore, we decided that the Plan does not have to pay for therapeutic procedure, on one or more areas, each lasting 15 minutes (97110) provided January 20, 2021.