Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 5 additional physical therapy (PT) visits.

You asked the Plan to pre-approve 5 additional PT visits. You say that the requested PT visits are necessary. The Plan denied your request. The Plan says the requested physical therapy visits are not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 

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 5 additional PT visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the provided documentation indicates that the enrollee appears to have plateaued with therapy. The reviewer found that further skilled therapy beyond the 25 approved visits at this point does not appear to be likely to achieve any significant improvement in the enrollee's symptoms or functional status. The reviewer found that the provided records do not include an encounter note from the enrollee's medical provider explaining the necessity of the 5 denied physical therapy sessions. Therefore, the reviewer found that the additional 5 visits are 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 5 additional PT visits have not been met. Specifically, the file shows that the enrollee has not likely to achieve any significant improvement with 5 additional visits. Therefore, we decided that the Plan does not have to pre-approve 5 additional physical therapy (PT) visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power mobility device (K0800).
You asked the Plan to pre-approve the power mobility device. You say that the PMD is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
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 capable of 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 the power mobility device. Our reviewer says that the requested PMD is not medically necessary. Our physician reviewer found the documentation provided including a physical therapy assessment in your home do not show that the enrollee can safely operate the device in the home.
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 power mobility device have not been met. Therefore, we decided that the Plan does not have to pre-approve a power mobility device (K0800).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex procedure (22869, 22870).
You asked the Plan to pre-approve a Vertiflex procedure. You say that the requested treatment is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met because the requested treatment is experimental/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 a Vertiflex procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee has chronic low back pain and lumbar spinal stenosis with neurogenic claudication. Imaging demonstrates multi-level lumbar disease. The enrollee has scoliosis of unreported degree. The record provided does not document that the enrollee is not a candidate for operative intervention at no more than two levels. 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 a Vertiflex procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex procedure (22869, 22870).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve percutaneous implantation of neurostimulator electrode array and implantable neurostimulator.
You asked the Plan to pre-approve percutaneous implantation of neurostimulator electrode array and implantable neurostimulator. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve percutaneous implantation of neurostimulator electrode array and implantable neurostimulator. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found auricular region stimulation with acupuncture remains experimental in pain management. More research is needed to show 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 percutaneous implantation of neurostimulator electrode array and implantable neurostimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve percutaneous implantation of neurostimulator electrode array and implantable neurostimulator
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve magnetic resonance imaging (MRI) and computed tomography (CT) scan of the cervical spine for the enrollee.
You asked the Plan to pre-approve the imaging. You say that this is medically necessary. The Plan denied your request. The Plan says that the records do not show results of prior picture studies such as x-ray or ultrasound.
The Plan must follow Medicare rules. Medicare rules say that CT scans and 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 imaging. Our reviewer says that the requested imaging is medically reasonable and necessary. Our physician reviewer found that in this case, the record indicates that the enrollee underwent multi-level cervical fusion in June 2021. The record indicates that the enrollee was seen in September and had developed bilateral numbness. The record indicates that plain films demonstrate subsidence and migration of hardware. The record indicates that operative intervention is planned and the provider requires the requested services. The record provided establishes the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. The elements of the coverage criteria are 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 imaging have been met. Therefore, we decided that the Plan has to pre-approve magnetic resonance imaging (MRI) and computed tomography (CT) scan of the cervical spine for the enrollee.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the durable medical equipment provided on May 10, 2021.

You asked the Plan to pay for the durable medical equipment. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.

The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery.

The record does not contain a valid proof of delivery for the supplies provided in this case. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the durable medical equipment provided on May 10, 2021.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve percutaneous transcatheter closure of congenital interatrial communication with implant 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 that the guidelines do not show evidence to support the performance of patient foramen ovale (PFO) closure patients at more advanced ages who do have significant traditional vascular risk.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 services. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has had recurrent strokes in a possible multi-embolic pattern while on therapeutic anticoagulation. Echocardiography also shows persistent thrombus on his right ventricular (RV) pacer leads. There is no history of paroxysmal atrial fibrillation (PAF) on pacer interrogation, and no large vessel vascular disease consistent with a carotid ischemic etiology. He has a documented large patient foramen ovale (PFO) with right to left shunting. He has been evaluated by both neurology and cardiology who concur that paradoxical embolism possibly from the RV pacer lead is a likely etiology of his prior strokes (especially in the absence of any other clear etiologies) and which resulted in neurologic debility, despite ongoing anti-coagulation. Although the health plan cited guidelines do not usually recommend closure in very elderly patients with other ischemic risk factors for stroke, this is a special situation with known thrombus on the pacer lead and prior failure of anticoagulation therapy in the setting of a large shunting PFO. Given this clinical scenario, percutaneous closure of the shunting PFO is reasonable and medically necessary, especially as he has clearly failed therapeutic anti-coagulation as an alternative to the PFO repair. 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 been met. Therefore, we decided that the Plan has to pre-approve percutaneous transcatheter closure of congenital interatrial communication with implant for the enrollee.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve x-rays to be provided by a tertiary provider.
You asked the Plan to pre-approve x-rays to be provided by a tertiary provider. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services can be provided by a non-tertiary provider.
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 x-rays to be provided by a tertiary provider. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation shows that you have chronic pain and stiffness in the knees and toes which developed after stopping Prednisone without tapering back in 1996 and is worsened with increased activity. The documentation supports that the requested x-ray services do not need to be done in the requested hospital setting. Your care needs can be adequately provided by a non-tertiary provider.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of x-rays to be provided by a tertiary provider have not been met. Therefore, we decided that the Plan does not have to pre-approve x-rays to be provided by a tertiary provider
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies for the enrollee.
You asked the Plan to pre-approve incontinence supplies. You say that incontinence supplies are medically necessary. The Plan denied your request. The Plan says incontinence supplies are not covered by Medicare.
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional physical therapy services (G0283, 97112,
97110, 97162).

You asked the Plan to pre-approve the additional physical therapy services. You say that the services are
medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient
therapy.

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 additional physical therapy services.
Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent
deterioration of the enrollee's condition. Our physician reviewer found the member has previously been treated
with outpatient therapies and should be independent with a home exercise program. There is no documentation
of a recent injury or decline in function. The additional therapy services are not of an appropriate duration and
frequency for treatment of the 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 the additional physical therapy services have not been met. Therefore, we
decided that the Plan does not have to pre-approve additional physical therapy services (G0283, 97112, 97110,
97162).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.

You asked the Plan to pre-approve foot orthotics. You say that foot orthotics are medically necessary. The Plan denied your request. The Plan says this item 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. 

The 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 foot orthotics.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ten (10) additional occupational therapy visits for the enrollee.
You asked the Plan to pre-approve ten (10) additional occupational therapy visits. You say that these services are medically necessary. The Plan denied your request. The Plan says that the clinical information does not
establish that the unique skills of an occupational therapist are needed to restore or maintain function or to prevent deterioration beyond the 10 approved visits.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 ten (10) additional occupational therapy visits. Our reviewer says that ten (10) additional occupational therapy visits are not medically reasonable and necessary for the enrollee is this case. The patient has had prior therapy and the records do not demonstrate that the ongoing unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or by or under the supervision of a therapist without completion of the already approved therapy. The patient has been instructed in and is compliant in a home exercise program. The requested services are not part of a maintenance program, and the specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design and/or deliver a program to maintain the patient's current condition or to prevent or slow further deterioration. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for ten (10) occupational therapy visits. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of ten (10) occupational therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve ten (10) additional occupational therapy visits for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Intracept procedure.

You asked the Plan to pre-approve an Intracept procedure. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve an Intracept procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Intracept procedure remans experimental for low back pain. More research is needed to show 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 an Intracept procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve an Intracept procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevator and expandable controller for a power wheelchair (E2300, E2377, E2313, E2311).
You asked the Plan to pre-approve the power wheelchair accessories. You say that these features are 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 power seat elevation functions are non-covered. Expandable controllers are covered only when 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 power wheelchair accessories. Our reviewer says that the requested features are not medically necessary. Our physician reviewer found the record shows that the enrollee is able to control the power options with their own switches which are included in the allowance for these power options. The expandable controller is not medically necessary and the seat elevator is not a covered item. 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 power wheelchair accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve a power seat elevator and expandable controller for a power wheelchair (E2300, E2377, E2313, E2311).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve precision attachment (D5862) for teeth #2, #6, #11, and #14 provided by a participating provider.
You asked the Plan to pre-approve precision attachment. You say that this should be covered because you only want four implants so you can chew food. The Plan denied your request. The Plan says the requested dental services are not a covered benefit.
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-approve precision attachment (D5862) for teeth #2, #6, #11, and #14 provided by a participating provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the subsequent observation care to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the subsequent observation care. You say that preauthorization is not required for outpatient services. You say the in-network facility should have obtained the proper referral. The Plan denied your request. The Plan says no prior authorization was obtained.
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 subsequent observation care to be provided by an out-of-network (OON) provider.