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

We decided that the Plan does not have to pre-approve spinal surgery.

You asked the Plan to pre-approve spinal surgery. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because the enrollee has not tried physical therapy, an epidural, or other pain management measures, has not had a consultation for non-surgical options, and has not quit smoking.

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 spinal surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there has been no recent trial and failure of physical therapy for the enrollee's condition. There are no red flags for surgery. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of spinal surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve spinal surgery.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the spinal fusion (CPT code(s): 22558, 22585 X 3, 22612, 22614 X 3, and 22842), for the enrollee.
You asked the Plan to pre-approve the spinal fusion. You say that it is your professional opinion that the enrollee is contraindicated for physical therapy due to their diagnosis of L4 compression fracture and significant DDD stenosis and L2-S1 severe degenerative disc disease. The Plan denied your request. The Plan says there is documented lumbar compression fracture, with central canal narrowing but no indication that there is instability or nerve root impingement requiring discectomy or stabilization and the enrollee has not had a significant trial of physical therapy. The Plan states their Interqual criteria are not met, and medical necessity of the proposed procedure is not 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 spinal fusion. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the criteria for surgery not met. The compression fracture is not unstable. Fusion surgery not needed. Decompression surgery not needed.
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 fusion have not been met. Therefore, we decided that the Plan does not have to pre-approve the spinal fusion (CPT code(s): 22558, 22585 X 3, 22612, 22614 X 3, and 22842), for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve computed tomography (CT) with quantitative evaluation of coronary calcium.
You asked the Plan to pre-approve CT with quantitative evaluation of coronary calcium. You say that the enrollee has mixed hyperlipidemia and is at risk for heart attack or stroke. The enrollee would medically benefit from insurance coverage of CT coronary calcium score which promotes his optimal health and wellbeing. The Plan denied your request. The Plan says the service in dispute is not covered by Medicare or under the enrollee's contract.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. Medicare rules also say that quantitative calcium scoring is not a covered service
and will be denied as not medically necessary. Therefore, we decided that the Plan does not have to pre-approve computed tomography (CT) with quantitative evaluation of coronary calcium.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an interspinous device procedure.

You asked the Plan to pre-approve insertion of interlaminar/interspinous process stabilization/distraction device
(22869, 22870, C1821). You say that if you do not get the surgery it will affect your motor skills of your lower
extremities. The Plan denied your request. The Plan says there are not enough studies on the device to show it
is safe and effective

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 insertion of interlaminar/interspinous
process stabilization/distraction device, without open decompression or fusion, including image guidance when
performed, lumbar; single level (22869), insertion of interlaminar/interspinous process stabilization/distraction
device, without open decompression or fusion, including image guidance when performed, lumbar; second
level (List separately in addition to code for primary procedure) (22870), and interspinous process distraction
device (implantable) (C1821). Our reviewer says that the requested items/services are not considered medically
reasonable and necessary in this case. Our physician reviewer found the device is experimental. More research
is needed to show safety and efficacy of interlaminar spacers.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of insertion of interlaminar/interspinous process stabilization/distraction device
(22869, 22870, C1821) have not been met. Therefore, we decided that the Plan does not have to pre-approve an
interspinous device procedure.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on February 26, 2021.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the services provided are not a covered benefit.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed in the Medicare rules section, are not covered.
The laboratory testing at issue in this appeal was requested solely for screening purposes. Medicare does not
cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the
laboratory services provided on February 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve proton beam therapy.

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 proton beam therapy is not routine
recommended for the treatment of prostate cancer outside of a prospective clinical trial or registry. There is no
compelling data to suggest that proton beam therapy is more beneficial than intensity modulated radiation
therapy (IMRT) or image-guided radiation therapy (IGRT). The services are therefore 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 proton beam therapy.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve gastroenterology services to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the OON gastroenterology services. You say that the medical records provided support the need for the services being requested. The Plan denied your request. The Plan says there are in-network liver clinics and gastroenterologists/hepatologists that are available and who can treat you.
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 gastroenterology services to be provided by an out-of-network (OON) provider.
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 requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.
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 you do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. There is not a reasonable expectation that you 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the diabetic shoes with inserts (CPT code(s): A5500 and A5512) to be purchased from an out-of-network provider.
You asked the Plan to pre-approve the diabetic shoes with inserts. You say that you are requesting review of denial of services. The Plan denied your request. The Plan says the out-of-network provider provides a specialized service where you are able to stay at home and they go to you. The Plan states there are in-network providers able to provide the services, but you would need to go there. The Plan states it is not noted that you are homebound.
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. Review of the file shows that you do not meet the Medicare definition of homebound. Furthermore, 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 diabetic shoes with inserts (CPT code(s): A5500 and A5512) to be purchased from an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an inpatient hospital admission.

You asked the Plan to pre-approve acute inpatient hospital care. You say that you disagree with the denial. The
Plan denied your request. The Plan says the inpatient level of care is not medically necessary.

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 the records show that you are scheduled for a cerebral angiogram and
treatment of an abnormal connection between arteries and veins (arteriovenous malformation). The records do
not support a reasonable expectation that you will require at least two midnights of inpatient hospital care for
the planned procedure. The inpatient level of care is therefore 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 acute inpatient hospital care have not been met. Therefore, we decided that the
Plan does not have to pre-approve an inpatient hospital admission.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric care from September 25, 2021, forward.
You asked the Plan to pre-approve inpatient psychiatric care from September 25, 2021, forward. You say that the services at issue are medically necessary. The Plan denied your request. The Plan says the services at issue are not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve inpatient psychiatric care from September 25, 2021, forward. Our reviewer says that you do not meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in question of September 25, 2021, forward. Our physician reviewer found you did not require inpatient mental health treatment beyond September 25, 2021, as you were not a danger to yourself or others and did not have any delusions, auditory or visual hallucinations. It did not appear that active treatment was taking place beyond the date in question. It did not appear that the services for the dates in question were reasonably expected or medically necessary to improve your condition or for the purpose of diagnosis. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient psychiatric care from September 25, 2021, forward have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from September 25, 2021, forward.
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 admission to an LTACH is medically necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically necessary.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the present setting where he is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. 

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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Freestyle Libre for the enrollee.
You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your request. The Plan says the current treatment plan includes a once daily subcutaneous injection of Basaglar.
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. Additionally, E1399 is not the correct code to use for this request. This type of monitor is traditionally requested with K0553 and K0554. 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 the Freestyle Libre for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve transthoracic echocardiography 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 further imaging can only be approved when additional tests are needed to direct care.
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 record indicates that the enrollee has nonischemic cardiomyopathy diagnosed in April 2021. At the time she also had atrial fibrillation with rapid ventricular response and underwent cardioversion. The record indicates than an echocardiogram was requested for June 2021 and that the plan approved this request. The provided records do not support the medical necessity and reasonableness, as defined by Medicare rules, of the requested repeat service for the enrollee's specific condition at this time. The elements of the coverage criteria 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve transthoracic echocardiography for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the home ventilator (CPT code E0466).
You asked the Plan to pre-approve the home ventilator. You say that the home ventilator is necessary. The Plan
denied your request. The Plan says the request for a home mechanical ventilator set in average volume assured
pressure support (AVAPS) mode that could be delivered by bilevel positive airway pressure (BiPAP) is not
covered.
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory
failure due to COPD.
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 home ventilator. Our physician
reviewer found a home ventilator is not medically necessary. You have severe chronic obstructive pulmonary
disease (COPD), but there is no documentation of carbon dioxide (CO2) retention on an arterial blood gases
(ABG), done while you are awake and medically stable. The ventilator is being prescribed as BiPAP, which is
not covered by Medicare. Certain BiPAP devices can provide the AVAPS mode of support. There is no
documentation of BiPAP failure.
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 home ventilator have not been met. Therefore, we decided that the Plan does
not have to pre-approve the home ventilator (CPT code E0466).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the breast reconstruction to be performed by an out-of-network provider.
You asked the Plan to pre-approve the services. You say that you are requesting review of denial of services. The Plan denied your request. The Plan says the services can be rendered by an in-network provider.
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 breast reconstruction to be performed by an out-of-network provider.