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

We decided that the Plan does not have to pre-approve spinal fusion.

You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your request. The Plan says the information submitted was not sufficient to support this 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 pre-approve the surgery. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no instability documented. The interspinous spacer device is experimental. The criteria for fusion is not met. 

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 surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve spinal fusion.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Feraheme (Q0138), an intravenous iron treatment.  You asked the Plan to pre-approve Feraheme. You say that the requested drug is medically necessary. The Plan denied your request. The Plan says the enrollee has not tried and failed the required drugs, Ferrlecit, Infed or Venofer.  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 Feraheme. Our reviewer says that the requested intravenous iron treatment is not medically necessary. Our physician reviewer found while the appeal letter claims that the enrollee has used multiple forms of oral iron, the provided medical record contains no evidence of this.  The reviewer found there is no evidence that the enrollee is allergic to or intolerant of oral iron. The reviewer found there is no evidence that the enrollee has tried and not responded to oral iron. The reviewer found there is no documentation as to why oral iron would not be expected to be safe and effective for the enrollee.  Therefore, the reviewer found that the requested intravenous (IV) iron is not shown to be currently medically necessary and reasonable.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Feraheme have not been met. Specifically, the file does not indicate that the enrollee has tried and failed oral iron. Therefore, we decided that the Plan does not have to pre-approve Feraheme (Q0138), an intravenous iron treatment.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a platelet-rich plasma injection.

You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says the effectiveness of this request has not been established.

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 injection. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found based on the medical records provided and the Medicare-approved major drug compendia there is no documentation that the platelet-rich plasma injection at issue in this case meets Medicare criteria for medically reasonable and necessary. As detailed in Micromedex/Drugdex use of platelet-rich plasma for osteoarthritis of the knee carries a strong recommendation against use. 

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 injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a platelet-rich plasma injection.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2311, E2313, E2377, K0108) for the enrollee.

You asked the Plan to pre-approve the services. You say that this is medically necessary. 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 the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee does not require non-proportional input devices (e.g., sip and puff, head array, etc.). The enrollee does not require a separate display (i.e., for alternate control devices), other electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive control), or an attendant control. The enrollee has 3 power options of tilt, recline, and power elevating leg rests on the approved Group 3 power wheelchair but the enrollee's left upper extremity strength and function support that the enrollee can control any power options through their own switches. 

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 pre-approve additional power wheelchair accessories (E2311, E2313, E2377, K0108) for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Sinuva.

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 services are not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has a diagnosis of nasal polyps. She has not tried and failed sinus surgery. The Food and Drug Administration has not stated that the requested drug is indicated for the enrollee's condition and the Medicare-approved drug compendia do not contain a supportive citation for the use of the requested drug in the enrollee's clinical situation. Sinuva 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 Sinuva.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor.  You asked the Plan to pre-approve the monitor. You say that you do not deserve this denial. The Plan denied your request. The Plan says this is not a covered benefit.  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 and have had an in-person visit with their treating physician to assesses adherence to their CGM regimen and diabetes treatment plan.    We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections or require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of the monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cleaning solution for a continuous positive airway pressure device (CPAP).

You asked the Plan to pre-approve the cleaner. You say that you do not have the funds to pay for these items. The Plan denied your request. The Plan says this does not serve a primarily 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-approve cleaning solution for a continuous positive airway pressure device (CPAP).
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to pay  an emergency room visit provided on April 10, 2021 coded as T81.30xs.  You asked the Plan to pay  this claim. You say that this claim should be paid. The Plan denied your request. The Plan says Medicare billing criteria are not met.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. 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 this claim. Our reviewer says that Medicare billing criteria are not met. Our reviewer found diagnosis code T81.30XS would not be reported as primary diagnosis.  Per ICD 10 guidelines Section 1, B, 10 "Sequela (Late Effects) A sequela is the residual effect (condition produced) after the acute phase of an illness or injury has terminated.  There is no time limit on when a sequela code can be used.  The residual may be apparent early, such as in cerebral infarction, or it may occur months or years later, such as that due to a previous injury.  Coding of sequela generally requires two codes sequenced in the following order: the condition or nature of the sequela is sequenced first.  The sequela code is sequenced second. Medicare billing criteria are not met.    We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this claim have not been met. Therefore, we decided that the Plan does not have to pay  an emergency room visit provided on April 10, 2021 coded as T81.30xs.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a segmental pneumatic compression device (E0652, E0668).

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says there is no documentation that the edema extends to the chest, trunk and/or abdomen.

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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found you are noted to have upper extremity lymphedema following a mastectomy. Your edema, symptoms and disability are noted to be improved while receiving basic treatments (i.e. compression wraps, massage). There is no evidence of a trial using a basic pump device (E0651) for four weeks resulting in treatment failure or intolerance. Therefore, the documentation does not support that a segmental pump (E0652) is currently medically necessary or reasonable. 

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 pre-approve a segmental pneumatic compression device (E0652, E0668).
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Evenity.  You asked the Plan to pre-approve Evenity. You say that the enrollee failed Prolia. The Plan denied your request. The Plan says the enrollee has not tried and failed bisphosphonates.   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 Evenity. Our physician reviewer found that in this case, the record indicates the enrollee has age related osteoporosis without osteoporotic fracture. The requested medication is a new start. The provided records do not indicate that the enrollee has tried and failed the plan's preferred step one alternative. The record does not indicate that the enrollee has a contraindication to or would have an adverse effect from the plan's preferred step one alternative.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Evenity have not been met. Therefore, we decided that the Plan does not have to pre-approve Evenity.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a panniculectomy.

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 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has intertrigo and a pannus that extends beneath the pubic symphysis. The records do not show a stable weight for a period of time nor is there documentation of failure of conservative treatment. The records do not establish that the panniculectomy is reasonable or medically necessary at this time. 

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 a panniculectomy.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the spinal cord stimulator.

You asked the Plan to pre-approve the spinal cord stimulator. You say that you would like reconsideration because the requested spinal cord stimulator is medically necessary to treat your condition. The Plan denied your request. The Plan says the records submitted indicate that conservative treatment has helped your condition.

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 spinal cord stimulator. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found you do not have an evidence based indication for a spinal cord stimulator trial. 

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 spinal cord stimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve the spinal cord stimulator.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Aranesp.  You asked the Plan to pre-approve Aranesp. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug does not meet step therapy criteria.   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 the documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer found the enrollee has diagnoses of Chronic kidney disease, stage 4 (severe), and Anemia in chronic kidney disease. The documentation does not support that the enrollee has tried and failed Retacrit (epoetin alfa) therapy for at least two consecutive months. The documentation does not support that Retacrit (epoetin alfa) would likely be less effective, and/or would likely have adverse effects for the enrollee in this case.  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.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lumbar facet joint radiofrequency ablation (RFA).

You asked the Plan to pre-approve a lumbar facet joint RFA. 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 follows Medicare rules. Medicare rules say that RFA 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 a lumbar facet joint RFA. Our reviewer says that the documentation does not support that the requested services are medically reasonable or necessary. Our physician reviewer found the enrollee has low back pain related to lumbar facet joint arthropathy. The provider notes a prior radiofrequency ablation (RFA) procedure to the lumbar spine was performed on September 17, 2018 and on October 5, 2018. According to the LCD, if there is an extended time, two years or more, since the last RFA and/or there is a question as to the source of the recurrent pain then diagnostic procedures must be repeated. In this case, the last RFA procedure was greater than three years ago. This means that the documentation has determined that the enrollee does not have a diagnosis/condition that meets the coverage criteria for the requested service. 

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 lumbar facet joint RFA have not been met. Therefore, we decided that the Plan does not have to pre-approve a lumbar facet joint radiofrequency ablation (RFA).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the acute inpatient hospital care.

You asked the Plan to pre-approve acute inpatient hospital care. You say that you would like reconsideration because the inpatient admission is medically necessary. The Plan denied your request. The Plan says the procedure is currently approved as an ambulatory procedure.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 

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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found there is no documentation provided to support the expectation the enrollee will require a greater than 2 midnight stay. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pre-approve the acute inpatient hospital care.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.  You asked the Plan to pre-approve SNF services. You say that SNF admission is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not 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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have documented skilled nursing needs.  The enrollee does not have documented skilled therapy needs.  The enrollee is ambulating more than 100 feet and tending to daily activities with minimal supervision.  Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollee's 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.