Persius/hicric huggingface dataset:
Appeal type: Step-Therapy
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Monovisc 88 mg/4 mL syringe.  You asked the Plan to pre-approve Monovisc. You say that this drug is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says step therapy criteria have not been met.  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 Monovisc. Our reviewer says that the requested services are not medically reasonable and necessary. Our physician reviewer found the Plan requires a trial of Druolane, Euflexxa, Supartz and GelSYN-3 before they will approve the requested drug. In this case, the patien has not tried and failed the required drug(s). There is no documentation provided indicating that the Plan's required drug(s) would likely be less effective and/or likely have adverse effects for the enrollee.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Monovisc have not been met. Therefore, we decided that the Plan does not have to pre-approve Monovisc 88 mg/4 mL syringe.
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 requested device. The Plan denied your request. The Plan says the enrollee does not meet the criteria.  The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 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 assess adherence to their CGM regimen and diabetes treatment plan.    We looked at the file and Medicare rules. The documentation does not indicate that the enrollee uses insulin with at least three daily injections or requires 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 requested device have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the application of a skin substitute graft (15271 and 15272) provided on March 3, 2021.  You asked the Plan to pay for the application of a skin substitute graft. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation does not support the services 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.  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 application of a skin substitute graft. Our reviewer says that CPT code 15271 does not meet criteria for billing or reimbursement consideration. The medical records does not include sufficient documentation to validate that an application of skin substitute graft to trunk, arms, legs , total wound surface area up to 100 sq cm,  first 25 sq cm or less wound surface area was the service that was performed on March 3, 2021, therefore this service cannot be verified.  Our reviewer found CPT code 15272 does not meet criteria for billing or reimbursement consideration. The medical records does not include sufficient documentation to validate that an application of skin substitute graft to trunk, arms legs total wound surface area up to 100 sq cm wound surface area or part thereof (List separately in addition to code for primary procedure) was the service that was performed on March 3, 2021.  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 application of a skin substitute graft have not been met. Therefore, we decided that the Plan does not have to pay for the application of a skin substitute graft (15271 and 15272) provided on March 3, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the insertion of a Vertiflex device (22869).  You asked the Plan to pre-approve the insertion of a Vertiflex device. You say that this is medically necessary. The Plan denied your request. The Plan says this 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 insertion of a Vertiflex device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental. More research is needed to show it is safe and effective.   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 insertion of a Vertiflex device have not been met. Therefore, we decided that the Plan does not have to pre-approve the insertion of a Vertiflex device (22869).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the transcutaneous electrical modulation pain reprocessing (TEMPR) rendered on July 14, 2021.  You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were 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 pay for these services. Our reviewer says that the services were not medically necessary. Our physician reviewer found the records show that you had a stroke that left you with left-sided nerve pain. The TEMPR procedure is considered experimental/investigational in nature and was 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 pay for the transcutaneous electrical modulation pain reprocessing (TEMPR) rendered on July 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve transforaminal epidural steroid injections.  You asked the Plan to pre-approve transforaminal epidural steroid injections. You say that you need to continue to get injections. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because the Plan already approved 2 injections and no more than 2 transforaminal epidural steroid injections should be performed in a single setting.  The Plan follows Medicare rules. Medicare rules state that transforaminal epidural steroid injections involving a maximum of two levels in one spinal region are considered medically 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 transforaminal epidural steroid injections. Our reviewer says that you do not meet the Medicare criteria for transforaminal epidural steroid injections beyond what the Plan already approved. Our physician reviewer found transforaminal epidural steroid injections involving a maximum of 2 levels in one spinal region are considered medically reasonable and necessary, but the Plan has already approved 2 injections.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of transforaminal epidural steroid injections have not been met. Therefore, we decided that the Plan does not have to pre-approve transforaminal epidural steroid injections.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services (81479) provided on May 2, 2021.  You asked the Plan to pay for the laboratory services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the submitted claim form indicates the laboratory specimen was obtained in a laboratory, POS 81; however, the submitted medical documentation indicates that the specimen was obtained in an On Campus Outpatient Hospital POS 22.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.   We find that CPT code 81479 is not supported in the record. Specifically, the claim was billed with the laboratory place of service code, but the record indicates that the member's face-to-face service was rendered in an outpatient hospital. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services (81479) provided on May 2, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).  You asked the Plan to pre-approve SNF admission. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested admission is not medically necessary.  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 admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you received oral medications. You had stable vital signs. You had routine foley catheter care. You required stand-by assistance to modified independence for functional mobility. The documentation does not support that you require the specialized skill, knowledge and judgment of a skilled professional nurse required to safely and effectively provide medically necessary and reasonable treatment. The documentation does not support that you require skilled nursing or skilled therapy services on a daily basis. Your 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 SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Drugs
Decision: Favorable

 We decided that the Plan has to pre-approve Alimta (pemetrexed) treatments.  You asked the Plan to pre-approve the requested Alimta treatment. You say that this should be covered due to medical necessity. The Plan denied your request. The Plan says that this is not medically necessary.  The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 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 the requested Alimta treatment. Our reviewer says that the requested Alimta treatment is considered medically reasonable and necessary. Our physician reviewer found the enrollee is a female with high grade serous carcinoma of the Fallopian tube. She has had several prior lines of therapy. Alimta as a single agent is now requested due to progression of disease. While this drug is not FDA-approved for this condition, it is supported as an off-label indication in the Lexicomp compendium.  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 requested Alimta treatment have been met. Therefore, we decided that the Plan has to pre-approve Alimta (pemetrexed) treatments.   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: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Moderate Sedation (01992) for the enrollee.  You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the medical records do not indicate any medical issue which is significant enough to warrant the need to provide conscious sedation or MAC.  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 requested services are not considered medically reasonable and necessary in this case. Neither conscious sedation nor Monitored Anesthesia Care (MAC) is routinely necessary for intra-articular facet joint injections or medial branch blocks and are not routinely reimbursable. Individual consideration may be given for payment in rare unique circumstances if the medical necessity of sedation is unequivocal and clearly documented. The medical records do not indicate any medical issue which is significant enough to warrant the need to provide conscious sedation or MAC, and the presence of a stable, treated condition of itself is not necessarily sufficient. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these services.  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 Moderate Sedation (01992) for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve computed tomography (CT) soft tissue neck (70490) computed tomography (CT) thorax (71250) computed tomography (CT) abdomen and pelvis (74176).  You asked the Plan to pre-approve the CT scan. You say that the medical records provided will show proof of medical necessity. The Plan denied your request. The Plan says records do not support that the services are medically necessary for the enrollee's condition.  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 CT scan. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found routine surveillance imaging stage I disease is not recommended.  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 CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve computed tomography (CT) soft tissue neck (70490) computed tomography (CT) thorax (71250) computed tomography (CT) abdomen and pelvis (74176).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve genicular nerve block (CPT code 64624), for the enrollee.  You asked the Plan to pre-approve the service. You say that the enrollee had previous bilateral genicular nerve block and reported 80% relief from the injection with noticeable functional improvement and decreased pain. The Plan denied your request. The Plan says there is not enough medical proof that shows the safety and/or success of this treatment, so it is considered experimental and/or unproven.  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 service. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is limited published, large-scale, long-term peer-reviewed literature that shows the request to be an effective and/or safe treatment for the noted pathology. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines. Therefore, the request for genicular nerve block (CPT 64624) is 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 service have not been met. Therefore, we decided that the Plan does not have to pre-approve genicular nerve block (CPT code 64624), for the enrollee.
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 she 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: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the Intracept procedure.  You asked the Plan to pre-approve Intracept. You say that the enrollee needs relief from his ongoing pain but wants to avoid invasive surgery. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because there is insufficient evidence of the efficacy of Intracept.  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 Intracept. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found Intracept is an experimental/investigational procedure.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Intracept have not been met. Therefore, we decided that the Plan does not have to pre-approve the Intracept procedure.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for neurophysiology services (procedure codes 95870, G0453) provided to the enrollee on February 24, 2021.  You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the documents do not support that these procedures were distinct or independent from other services performed.  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 the denied codes is:  CPT 95870:  Needle electromyography; limited study of muscles in 1 extremity or non-limb (axial) muscles (unilateral or bilateral), other than thoracic paraspinal, cranial nerve supplied muscles, or sphincters  Healthcare Common Procedure Coding System (HCPCS) G0453:  Continuous intraoperative neurophysiology monitoring, from outside the operating room (remote or nearby), per patient, (attention directed exclusively to one patient) each 15 minutes (list in addition to primary procedure)  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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer found the technical report does not support that the denied codes are a distinct and separate service from CPT 95861. Therefore, they should not be unbundled.  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 services have not been met. Therefore, we decided that the Plan does not have to pay for neurophysiology services (procedure codes 95870, G0453) provided to the enrollee on February 24, 2021.