Persius/hicric huggingface dataset:
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 enrollee will benefit from 3 hours of rehab to help return to the highest level of function. The Plan denied your request. The Plan says the enrollee does not require an interdisciplinary team approach to rehabilitation care.  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 physician reviewer found that the enrollee was admitted to the acute care hospital for surgical repair of a hip fracture after a fall. Her medical problems are stable. She does not require treatment by multiple therapies in an intensive rehabilitation therapy program. While she has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program.  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: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Feraheme.  You asked the Plan to pre-approve Feraheme. You say that the medication is necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.  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 Feraheme. Our reviewer says that the medication is not medically necessary. Our physician reviewer found the documentation does not support that the Feraheme is medically reasonable and necessary or safe and effective for you.  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. Therefore, we decided that the Plan does not have to pre-approve Feraheme.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the skin procedure (17999) provided on February 8, 2021.  You asked the Plan to pay for the skin procedure. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support the service billed.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.  In this case, the CPT Code Manual definition of code 17999 is unlisted procedure, skin, mucous membrane and subcutaneous tissue.  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 skin procedure. Our reviewer says that CPT code 17999 does not meet criteria for billing or reimbursement consideration. Our reviewer found the documentation does not support an unlisted procedure code was performed.  Coding should be to the highest specificity, and an unlisted code should be reported only if no code exists for the procedure performed.  When an unlisted procedure is reported.  Per documentation CPT 17999 is being reported for "Somagen Dermal Matrix 6x8 cm.  For this service a more appropriate Healthcare Common Procedure Coding System (HCPCS) code should be reported.  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 skin procedure have not been met. Therefore, we decided that the Plan does not have to pay for the skin procedure (17999) provided on February 8, 2021.
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 is not medically necessary.  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 based on the documentation provided you do not require the intensity of services provided at an IRF. Specifically, you are not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. 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 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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office visit and related services provided on February 8, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the office visit. You say that the care provided was medically necessary. The Plan denied your request. The Plan says prior authorization was not obtained for these services rendered by an OON 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 pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.  The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the office visit and related services provided on February 8, 2021, 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 you need inpatient rehabilitation services. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. The services you need can be provided in an alternate setting.  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 based on the documentation provided, you do not appear to require the intensity of services provided at an IRF. Specifically, you are not shown to require fifteen hours per week of rehabilitative services with regular physician evaluation. Your care needs can be met in an alternate setting.  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: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a magnetic resonance image (MRI) of the lower extremity.  You asked the Plan to pre-approve an MRI of the lower extremity. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.  The Plan must follow Medicare rules. Medicare rules say that 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 an MRI of the lower extremity. Our reviewer says that the services are not medically necessary. Our physician reviewer found the requested service is not medically necessary and reasonable for the diagnosis and treatment for the enrollee's clinical condition at this time. The elements of the coverage criteria are not satisfied. The requested service cannot be 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 an MRI of the lower extremity have not been met. Therefore, we decided that the Plan does not have to pre-approve a magnetic resonance image (MRI) of the lower extremity.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the muscle, myocutaneous, or fasciocutaneous flap (15738) provided on April 23, 2021.  You asked the Plan to pay for the muscle, myocutaneous, or fasciocutaneous flap. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support the service billed.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.  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 muscle, myocutaneous, or fasciocutaneous flap. Our reviewer says that CPT code 15738 does not meet criteria for billing or reimbursement consideration. Our reviewer found the medical records provided does not include sufficient documentation to validate that a muscle, myocutaneous, or fasciocutaneous flap; lower extremity was performed on April 23, 2021, therefore this service cannot be verified.  We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the muscle, myocutaneous, or fasciocutaneous flap have not been met. Therefore, we decided that the Plan does not have to pay for the muscle, myocutaneous, or fasciocutaneous flap (15738) provided on April 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the mandibular partial denture (D5222).

You asked the Plan to pre-approve the mandibular partial denture. You say that this is medically necessary for your condition. The Plan denied your request. The Plan says this is not a covered service according to Medicare or the Plan's supplemental 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 the mandibular partial denture (D5222).
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the insertion of stabilization device (22869 and 22870).  You asked the Plan to pre-approve the insertion of stabilization device (22869 and 22870). You say that the member has suffered from this condition for greater than 6 months and has failed at least 6 months of conservative approaches to treatment. You say that they meet all the approved indications for the Vertiflex procedure, and the treatment should be approved. The Plan denied your request. The Plan says unproven and not medically necessary procedures are not covered.  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 stabilization device (22869 and 22870). Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that interlaminar devices are experimental. 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 the insertion of stabilization device (22869 and 22870) have not been met. Therefore, we decided that the Plan does not have to pre-approve the insertion of stabilization device (22869 and 22870).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a repeat lumbar epidural steroid injection.  You asked the Plan to pre-approve a repeat lumbar epidural steroid injection. You say that this is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage have not been met.  The Plan must follow Medicare rules. Medicare rules say that repeat ESI services will be covered if they provide at least 50% of sustained improvement in pain relief and/or improvement in function for at least three months.   We looked at the file and Medicare rules. Although you indicate that it has led to 50% pain relief for the enrollee's condition, it has not been 3 months since the initial injection. Based on this information, we decided that Medicare rules for coverage of a repeat lumbar epidural steroid injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a repeat lumbar epidural steroid injection.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bioimpedance spectroscopy.

You asked the Plan to pre-approve bioimpedance spectroscopy. 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 bioimpedance spectroscopy. Our
reviewer says that the requested items/services are not considered medically reasonable and necessary in this
case. Our physician reviewer found current evidence suggests that bioimpedance spectroscopy, extracellular
fluid analysis may not be more accurate than standard and simpler in-office assessment techniques for
measuring lymphedema risk. There is also insufficient high-quality evidence to suggest this method leads to
improved outcomes compared to simpler methods. Without sufficient support made for this test, it will be
considered 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 bioimpedance spectroscopy have not been met. Therefore, we decided that the
Plan does not have to pre-approve bioimpedance spectroscopy.
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 is not medically necessary.

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 the complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do require physical therapy and occupational therapy services but based on the medical records provided you do not require an intensive inpatient rehabilitation therapy program. Medically necessary services can be provided in a different level of care. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an oral evaluation and prosthesis to be performed by a prosthodontist.

You asked the Plan to pre-approve an oral evaluation and prosthesis to be performed by a prosthodontist. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

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. The Plan says covered services must be performed by a participating general dentist. 

We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of an oral evaluation and prosthesis to be performed by a prosthodontist have not been met. Therefore, we decided that the Plan does not have to pre-approve an oral evaluation and prosthesis to be performed by a prosthodontist.
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 based on the documentation provided you appear to not be stable enough for transfer at this time. Acute care services can be safely administered at the current facility for the time being until treatment is completed and transfer to a lower level of care is more appropriate. You do not require services at the LTACH that are not already available at the current facility. There are no services at the LTACH that you require that are not already available and covered at the current facility.  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: 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 records provided support the need for IRF care. You say that the enrollee will not be able to regain maximum function if admission to an IRF is delayed. The Plan denied your request. The Plan says IRF care is not medically necessary and that a lower level of care is more appropriate.  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 the enrollee does not require the intensity of services provided at an IRF.  Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation.  The enrollee's care needs can be met at a lower level of care.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.