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

We decided that the Plan does not have to pre-approve a bilateral breast magnetic resonance imaging (MRI) scan with and without contrast (77049). You asked the Plan to pre-approve this service. You say that this service is medically necessary for the enrollee. The Plan denied your request. The Plan says this service is not medically necessary. The Plan must follow Medicare rules. Medicare rules say that breast MRI studies are to be used very selectively. 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 preapprove this service. Our reviewer says that a bilateral breast MRI is not medically necessary. Our physician reviewer found that per the reviewed documentation, the enrollee has had two benign breast biopsies in the past. There is no personal or family history of breast cancer. There is nothing else she has had in the way of genetic mutations. The enrollee's request for an MRI started on recommendation of her radiologist due to dense breast tissue. She has a 7.9% lifetime risk of breast cancer with dense breasts on mammogram. A breast MRI is indicated in the surveillance of women with greater than or equal to 20% lifetime risk of breast cancer (for example, individuals with genetic predisposition to breast cancer as determined by either gene testing or family pedigree, or individuals with a history of mantle radiation for Hodgkin lymphoma). High-risk patients may be referred for an annual screening breast MRI in addition to mammography, preferably after risk assessment and counseling either by personnel trained in the assessment of hereditary breast cancer or by a referring physician who has used a breast cancer risk assessment model. The review has determined that the requested breast MRI is not medically necessary or reasonable. We looked at the physician's review, the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pre-approve a bilateral breast magnetic resonance imaging (MRI) scan with and without contrast (77049).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services for the enrollee.You asked the Plan to pre-approveIRF care. You say that these services are medically necessary.The Plan denied your request. The Plan says that the enrollee can safely receive the services needed in other settings.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 rulesto 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. 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 shortness of breath and peripheral edema. He was treated for acute on chronic congestive heart failure and respiratory failure. The enrollee's medical conditions are stable. There are no medical needs requiring inpatient admission. 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 documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. 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. Our physician reviewer found that the enrollee's condition does not meetMedicare criteria for IRF 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-approveacute inpatient rehabilitation facility (IRF) admission and services for the enrollee
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean fitness memberrship.You asked the Plan topre-approvean fitness membership. You say that your previous plan covered your gym membership.The Plan denied your request. The Plan says this is not a covered benefit under your Plan.The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers access to' Healthy Living centers.The Plan's rules for coverage of gym benefits have not been met becausethe fitness center is not a Healthy Living center.Therefore, we decided that the Plan does not have to pre-approvean the fitness membership
Appeal type: Surgery
Decision: Unfavorable

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

We decided that the Plan has to pre-approve CT scan of the abdomen for the enrollee. You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your request. The Plan says that there are no results of an exam from the doctor that show why this exam is needed. 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 scan. Our reviewer says that the requested scan is medically reasonable and necessary. Our physician reviewer found there is no requirement for physical exam or any other documentation other than being one year out from cryoablation for renal cell cancer. 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 scan have been met. Therefore, we decided that the Plan has to pre-approve CT scan of the abdomen for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Privigen and Actemra.
You asked the Plan to pre-approve Privigen and Actemra. You say that Privigen and Actemra are medically necessary. The Plan denied your request. The Plan says Privigen and Actemra are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Privigen and Actemra. Our reviewer says that Privigen and Actemra are not medically necessary. Our physician reviewer found in this case, Privigen (immune globulin) and Actemra (tocilizumab) are being used to treat and suppress antibodies that are developing after cardiac transplantation. These drugs are not covered by Medicare when used to treat this condition because it is not FDA approved for this use and is not supported in Medicare drug references. Off label uses of these medications also do not include treatment for the condition requested. Coverage criteria are not met since medical necessity is not supported by consideration of "major drug compendia, authoritative medical literature and/or accepted standards of medical practice". We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Privigen and Actemra have not been met. Therefore, we decided that the Plan does not have to pre-approve Privigen and Actemra.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for cystourethroscopy (52214) provided on May 18, 2020. You asked the Plan to pay for the cystourethroscopy. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support the service 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 CPT Code Manual definition of code 52214 is cystourethroscopy, with fulguration (including cryosurgery or laser surgery) of trigone, bladder neck, prostatic fossa, urethra, or periurethral glands. We asked our coder 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 cystourethroscopy. Our reviewer says that CPT code 52214 does not meet criteria for billing or reimbursement consideration. Our reviewer found the medical records provided do not included sufficient documentation to validate that a cystourethroscopy, with
fulguration (including cryosurgery or laser surgery) of trigone, bladder neck, prostatic fossa, urethra, or periurethral glands was performed on May 18, 2020, therefore the procedure cannot be verified. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the cystourethroscopy have not been met. Therefore, we decided that the Plan does not have to pay for cystourethroscopy (52214) provided on May 18, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that IRF care is medically necessary for the enrollee.The Plan denied your request. The Plan says rules for IRF care 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 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 enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. 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-approveacute inpatient rehabilitation facility (IRF) admissionand services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve custom orthotics.
You asked the Plan to pre-approve foot orthotics. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve custom orthotics.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea SoClean CPAP cleaner.You asked the Plan to pre-approvethis item. You say that you are unable to clean your CPAP.The Plandenied your request. The Plan says that the requested SoClean device is not considered to be durable medical equipment as it does not primarily serve a medical purpose.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured.Therefore, we decided that the Plan does not have to pre-approvea SoClean CPAP cleaner
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve removal of tendon for graft (20924), removal of wrist bone (25210), and repair of wrist joints (25447).
You asked the Plan to pre-approve removal of tendon for graft, wrist bone, and repair of wrist joints. You say that the service is medically necessary. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve removal of tendon for graft, wrist bone, and repair of wrist joints. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is limited documentation of any trial and failure of conservative care modalities provided for review and guidelines do not support this requested surgical procedure without prior failure of conservative treatment. Exceptional findings are not evident in this scenario to support otherwise. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of removal of tendon for graft, wrist bone, and repair of wrist joints have not been met. Specifically, the services are not considered medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve removal of tendon for graft (20924), removal of wrist bone (25210), and repair of wrist joints (25447).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe abutment services (D6057 and D6059).You asked the Plan to pre-approvethe dental services. You say that you would like reconsideration because you are presenting signs and symptoms of tooth pain and infection.The Plan denied your request. The Plan says these services are not covered 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 pre-approvethe abutment services (D6057 and D6059)
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex Superion Spacer.
You asked the Plan to pre-approve the Vertiflex Superion Spacer. You say that you would like reconsideration
because the spacer is medically necessary. The Plan denied your request. The Plan says this service is
experimental.
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 Superion Spacer. Our
reviewer says that the requested items/services are not considered medically reasonable and necessary in this
case. Our physician reviewer found the spacer device is experimental and more research is needed to show its
safety and efficacy.
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 Superion Spacer have not been met. Therefore, we decided that the
Plan does not have to pre-approve the Vertiflex Superion Spacer.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued coverage of a Continuous Positive Air Pressure (CPAP) device (E0601). You asked the Plan to pre-approve continued coverage of the CPAP device. You say that continued use of the CPAP is medically necessary. The Plan denied your request. The Plan says rules for coverage are not met.
The Plan follows Medicare rules. Medicare rules say that adherence to therapy is defined as use of PAP more than 4 hours per night on 70% of nights. 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 continued coverage of the CPAP device. Our reviewer says that the CPAP device is not medically necessary. Our physician reviewer found there is no evidence that the patient has been able to use the device enough for it to be effective. CPAP is considered not medically necessary because of inadequate use 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 continued coverage of the CPAP device have not been met. Therefore, we decided that the Plan does not have to pre-approve continued coverage of a Continuous Positive Air Pressure (CPAP) device (E0601).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a sacral lateral nerve branch block for the enrollee.
You asked the Plan to pre-approve the block. You say that this is medically necessary. The Plan denied your request. The Plan says this is considered experimental and investigational.
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 block. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this is considered an experimental and investigational procedure because of the wide variation in efficacy in the literature. Therefore, the request is considered 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 block have not been met. Therefore, we decided that the Plan does not have to pre-approve a sacral lateral nerve branch block for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea Group 2 power wheelchair and accessories.You asked the Plan to pre-approvea power wheelchair, Group 2 standard, multiple power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds (K0841), wheelchair accessory, addition to power seating system, center mount power elevating leg rest/platform, complete system, any type, each (E1012). You say that the enrollee is not a functional ambulatory and needs the power wheelchair to continue with MRADLs.The Plan denied your request. The Plan says the Group 2 power wheelchairwith power tilt/recline and power elevating leg rests exceeds the enrollee's needs.The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capableof safely operating the requested PMD. 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 power wheelchair, Group 2 standard, multiple power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds (K0841), wheelchair accessory, addition to power seating system, center mount power elevating leg rest/platform, complete system, any type, each (E1012). Our reviewer says that the power wheelchair is not medically necessary and exceeds the enrollee's needs. Our physician reviewer found the therapy and medical progress report documentation indicates that this patient has a personal mobility deficitbut it is not clear that this deficit impairs participation in MRADLs in the home or why the patient's mobility deficit cannot be helped effectively by a walker or manual wheelchair in the home. The documentation does not reveal thepatient is unable to perform a functional weight shift; utilizes intermittent catheterization for bladder management, or that this seating system is neededto manage tone or spasticity. While the patient may be able to safely use the requested power wheelchair the Group 2 multiple power options wheelchair and accessories is 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 a power wheelchair, group 2 standard, multiple power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds (K0841), wheelchair accessory, addition to power seating system, center mount power elevating leg rest/platform, complete system, any type, each (E1012) havenot been met.Therefore, we decided that the Plan does not have to pre-approvea Group 2 power wheelchair and accessories.