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

We decided that the Plan does not have to pay for assistant surgeon services provided to the enrollee on December 9, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the requested service code is not substantiated by the clinical documentation in the operative report submitted for review.
The Plan follows Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. Medicare rules say that for procedures with an assistant surgery indicator of 0, the payment restriction for assistants at surgery applies to this procedure unless supporting documentation is submitted to establish medical necessity. In this case, you billed assistant surgery services for CPT code 29881. The Medicare Fee Schedule Database contains a surgical indicator of 0 for this procedure. 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 services. Our reviewer says that the services at issue in this case were not medically reasonable or necessary. Our physician reviewer found the enrollee underwent a left knee arthroscopic partial medial meniscectomy, chondroplasty of the lateral tibial plateau, and two-compartment synovectomy of the medial and patellofemoral aspect of the plica on 12/9/19. Under consideration is a request for assistant at surgery services for this procedure. The Medicare Fee Schedule Database indicates that an assistant at surgery is generally not medically necessary for CPT code 29881. There is no detailed documentation submitted to support the medical necessity of an assistant at surgery for this enrollee. There is no compelling patient-specific rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception to the Medicare rules. Therefore, the records do not support that an assistant surgeon was needed for CPT code 29881.
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 services have not been met. Therefore, we decided that the Plan does not have to pay for assistant surgeon services provided to the enrollee on December 9, 2019.
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 skilled nursing facility has COVID patients and the enrollee is at high risk.The Plan denied your request. The Plan says the guidelines for coverage have not been met. The Plan says that the care needed can be provided in another setting.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve 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 records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a skilled nursing facility (SNF) level of care. Ongoing pain medication and other medication management, wound care, and daily therapy can be provided at a SNF. The enrollee is mostly standby assist for functional transfers and activities of daily living. A less intensive, longer duration of therapy will allow for measurable gains to be attained within a predicted period.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for wrist hand orthosis (L3916) provided on December 6, 2019.
You asked the Plan to pay for the wrist hand orthosis. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted did not indicate the provider discussed the need for the billed supply code.
The Plan must follow Medicare rules. Medicare rules say that for any DMEPOS item to be covered by Medicare, the patient's medical record must contain sufficient documentation of the patient's medical condition to substantiate the necessity for the type and quantity of items ordered and for the frequency of use or replacement (if applicable). We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the wrist hand orthosis have not been met. Specifically, the record shows that the Plan requested progress notes to indicate the ordering provider discussed the need for the billed supply code. There is insufficient information to verify the billed supplies. Therefore, we decided that the Plan does not have to pay for wrist hand orthosis (L3916) provided on December 6, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aranesp for the enrollee. You asked the Plan to pre-approve Aranesp. You say that this is medically necessary. The Plan denied your request. The Plan says that they did not receive documentation supporting the medical necessity for a step therapy exception. 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 Aranesp. Our reviewer says that Aranesp is not medically reasonable and necessary for the enrollee in this case. The enrollee has not had an inadequate response to Retacrit (epoetin alfa) therapy for at least two consecutive months with appropriate dose adjustment. The documentation does not outline contraindications or reasons Retacrit was not considered. Our physician reviewer found that the enrollee's condition does not meet step therapy criteria for Aranesp. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Aranesp have not been met. Therefore, we decided that the Plan does not have to pre-approve Aranesp for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the OON spinal injection. You say that this service is necessary to treat your pain. The Plan denied your request. The Plan says the plan's network has providers who can provide the type of service requested in this case. As such, the OON providers requested are not necessary.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the medical services to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vertiflex Implant.
You asked the Plan to pre-approve Vertiflex Implant. 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 Vertiflex Implant. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee presents with persistent moderate low back pain radiating to the calf. Functional limitations are noted in activities of daily living. Clinical exam findings have documented sensory deficits in the left L5 and S1 dermatomal distribution. There is imaging evidence of moderate to severe central canal stenosis at L2/3, moderate lateral recess stenosis at L3/4 and L4/5, moderate to severe neuroforaminal stenosis at L4/5, and severe left neuroforaminal stenosis at L5/S1. The enrollee has reportedly failed to improve with reasonable and/or comprehensive conservative treatment. Authorization was requested for the Vertiflex implant procedure at two levels. Current evidence based medical guideline and peer reviewed literature do not fully support the spinal decompression device procedure over the 'gold standard' of lumbar laminectomy. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of this device for this enrollee's medical condition as discussed above. FDA indications include implantation of the Superion device at one or two adjacent lumbar levels in patients in whom operative treatment is indicated at no more than two levels, from L1 to L5. This enrollee has moderate to severe stenosis at all levels from L2/3 through L5/S1. There is no clear evidence that this enrollee had symptoms of neurogenic claudication, including relief in flexion. The April 2, 2020 authorization form indicates the procedure was requested at the L2/3 and L4/5 levels which would not be adjacent levels. According to the FDA indications, the safety and effectiveness of the Superion Interspinous Spacer had not been studied in enrollees with symptomatic lumbar spinal stenosis at more than 2 levels. Therefore, this enrollee does not have a diagnosis or condition or symptoms that fully meet Medicare coverage criteria. The Vertiflex implant would not be considered the standard of care or reasonable and medically necessary for treatment of this enrollee's medical condition. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Vertiflex Implant have not been met. Therefore, we decided that the Plan does not have to pre-approve Vertiflex Implant.
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 records provided support the need for LTACH care.The Plan denied your request. The Plan says the guidelines for coverage have not been met. The Plan says that the care needed can be provided in the current hospital.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 is currently undergoing treatment at an acute care hospital (ACH), where he was found to have a cervical spine injury resulting in respiratory depression/weakness. The enrollee was intubated/ventilated and subsequently received a tracheotomy. The enrollee remains on a ventilator and is not expected to be fully liberated from it. There is no evidence that the enrollee requires services that are not currently available. There is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such a time that no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long-term care needs.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 percutaneous implantation of neurostimulator electrodes sacral nerve (Interstim).
You asked the Plan to pre-approve the Interstim. You say that the enrollee will significantly benefit from percutaneous implantation of neurostimulator electrodes. You say that the clinical notes and medical history support the need for the requested services. The Plan denied your request. The Plan says there is no documentation of the enrollee being refractory to conventional therapy and being an appropriate surgical candidate. The Plan says that the service 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 the Interstim. Our reviewer says that percutaneous implantation of neurostimulator electrodes sacral nerve is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee must be refractory to conventional therapy and be an appropriate surgical candidate such that implantation with anesthesia can occur. A cystoscopy has not been performed to demonstrate absence of bladder outlet obstruction. Enrollees with stress incontinence, urinary obstruction, and specific neurologic diseases which are associated with secondary manifestations of the above three indications are excluded. The records provided state that this enrollee has flaccid neuropathic bladder, most likely due to long-term obstruction and/or diabetes. 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 Interstim have not been met. Therefore, we decided that the Plan does not have to pre-approve percutaneous implantation of neurostimulator electrodes sacral nerve (Interstim).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the cervical spine.You asked the Plan to pre-approve the MRI. You say that the records provided support the need for the requested MRI.The Plan denied your request. The Plan says the records show that the enrollee had the same study or a test like it. The Plan says that the records show the results of this test and that the enrollee's doctor has what they need to see in order to treat the enrollee's condition. The Plan says that repeat imaging is not supported without a clear reason for it.The Plan must follow Medicare rules. Medicare rules say that MRIs 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 MRI. Our reviewer says that the requested MRI is not medically reasonable and necessary. Our physician reviewer found the enrollee had a nerve conduction study of the upper extremities noting bilateral carpal tunnel syndrome, left ulnar neuropathy, and diffuse denervation of the right upper extremity. An MRI dated March 13, 2020 was completed and the results reviewed. A request for a repeat MRI was ordered on April 29, 2020. It is not clear from the reviewed records why a repeat study was ordered. There was no noted injury, significant change in symptoms, or discussion to support the repeat study. Without the documentation, medical necessity cannot be determined.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 MRI have not been met.Therefore, we decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the cervical spine.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the shower chair, grab bar, transfer bench rental,
hip kit and car handle purchased on August 30, 2019.
You asked the Plan to reimburse you for the shower chair, grab bar, transfer bench rental, hip kit and car
handle. You say that you needed these items so the Plan should pay the claims. The Plan denied your request.
The Plan says Medicare guidelines state that hygienic, comfort and convenience items are not primarily
medical in nature and therefore on-covered.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose.
The items at issue in this appeal do not serve a purpose that is primarily medical in nature. These items are
available to the general public and would be helpful even to those who are not sick or injured. Medicare rules
say that shower chairs and grab bars are not covered because they are not primarily medical in nature.
Therefore, we decided that the Plan does not have to reimburse you for the shower chair, grab bar, transfer
bench rental, hip kit and car handle purchased on August 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-ofnetwork
provider on June 7, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not
authorized.
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 has network providers
available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at
issue. 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 the medical services provided to the enrollee by an out-of-network provider
on June 7, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient services provided on December 5, 2019 through December 9, 2019.
You asked the Plan to pay for the outpatient services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the GP modifier is required at specified intervals on all claims for outpatient therapy services.
The Plan must follow Medicare rules. Medicare rules say that providers/suppliers must continue to report modifier GN, GO or GP for any therapy code on the list of applicable therapy codes. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the outpatient services have not been met. Specifically, revenue code 424 for Physical Therapy Evaluation was not billed with the required GP modifier. Therefore, we decided that the Plan does not have to pay for outpatient services provided on December 5, 2019 through December 9, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar sacral orthosis provided to the enrollee on December 26, 2019.You asked the Plan to pay for the orthosis. The Plan denied your request. The Plan says that the billed supply code cannot be verified.The Plan must follow Medicare rules. Medicare rules say that a spinal orthosis is covered for the above 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 pay for the orthosis. Our reviewer says that the orthosis was not considered medically reasonable and necessary in this case. Based on the medical records provided the spinal orthosis in this case does not meet the four above indications. Our physician reviewer found that the enrollee's condition did not meet Medicare criteria for the orthosis.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 orthosis have not been met.Therefore, we decided that the Plan does not have to pay for the lumbar sacral orthosis provided to the enrollee on December 26, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on September 18, 2019.You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.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 has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. 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 the medical services provided to the enrollee by an out-of-network provider on September 18, 2019.
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 records provided support the need for IRF care.
The Plan denied your request. The Plan says IRF care 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 above.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve 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 records do not indicate that there are significant, or complex medical/nursing
issues that could not be addressed at a skilled nursing facility (SNF) level of care. Ongoing medication
management, wound care, and daily therapy can be provided at a SNF. The enrollee is mostly MODERATE
assist for functional activities of daily living. A less intensive, longer duration of therapy will allow for
measurable gains to be attained within a predicted period.
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.