Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve injection (64454). 
 
You asked the Plan to pre-approve a genicular nerve injection. You say that the service is medically necessary. 
The Plan denied your request. The Plan says this service is considered 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 a genicular nerve injection. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found the role of genicular nerve blocks and of radiofrequency ablation (RFA) are the 
subject of ongoing clinical trials and is considered experimental at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a genicular nerve injection. have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a genicular nerve injection (64454).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the therapeutic procedures to be provided by an OON provider.

You asked the Plan to pre-approve the therapeutic procedures. You say that the treatment will improve the enrollee's function with methods such as massage, heat treatment and exercise. The Plan denied your request. The Plan says the enrollee does not have out-of-network coverage and have confirmed this service is available by a provider in-network.

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 therapeutic procedures to be provided by an OON provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 70450 billed for date of service October 19, 2022.

You asked the Plan to pay for procedure code 70450. You say that the enrollee had multiple exams on the date in question. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for code 70496.

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, we have confirmed that code 70450 is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 70450 billed for date of service October 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the proton beam therapy (PBRT) (77523).

You asked the Plan to pre-approve the proton beam therapy. You say that the service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary.

The Plan follows Medicare rules. Medicare rules say that Proton beam therapy will be considered medically reasonable and necessary when the criteria listed in the Medicare Rules section is met.

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 proton beam therapy. Our reviewer says that the service is not medically necessary. Our physician reviewer found the records do not show PBRT is the treatment of choice for enrollee. The records do not show the enrollee is being treated in a protocol that is designed for evidence development and future publication.

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 proton beam therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve the proton beam therapy (PBRT) (77523).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve stair lift repairs.

You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the request is not covered by Medicare.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.

Stair lifts do not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Because stair lifts are not a covered benefit, repairs are also not covered. Therefore, we decided that the Plan does not have to pre-approve stair lift repairs.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surface guided radiation therapy imaging. 
 
You asked the Plan to pre-approve surface guided radiation therapy imaging. You say that the requested 
surface guided radiation therapy imaging is medically necessary. The Plan denied your request. The Plan says 
the requested surface guided radiation therapy imaging is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve surface guided radiation therapy 
imaging. Our reviewer says that the requested surface guided radiation therapy imaging is not medically 
necessary. Our physician reviewer found palliative radiation (CPT 77412) is medically reasonable and 
necessary for the enrollee, which was approved by the Plan. However, surface guided radiotherapy (CPT 
G6017) is not. Surface guided radiotherapy (SGRT) is considered experimental/investigational. The clinical 
value of SGRT has not been unequivocally established in the medical literature. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of surface guided radiation therapy imaging have not been met. Therefore, we 
decided that the Plan does not have to pre-approve surface guided radiation therapy imaging.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that without therapy it is affecting the enrollee to be able 
to return to their baseline. The Plan denied your request. The Plan says a SNF 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 care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing or skilled therapy on an inpatient basis in a SNF 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Computed Tomography Angiography (CTA). 
 
You asked the Plan to pre-approve a Computed Tomography Angiography (CTA). You say that the requested 
Computed Tomography Angiography (CTA) is medically necessary. The Plan denied your request. The Plan 
says the requested Computed Tomography Angiography (CTA) is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a Computed Tomography Angiography 
(CTA). Our reviewer says that the requested Computed Tomography Angiography (CTA) is not medically 
necessary. Our physician reviewer found the record indicates that the enrollee has claudication with diminished 
peripheral pulses. The requested test was performed in 2021 and did not reveal significant aortic disease. The 
record does not document the results of a complete vascular examination or that arterial duplex ultrasound was 
performed. The record provided does not establish the medical necessity and reasonableness, as defined by 
Medicare rules, of the requested service. The elements of the coverage criteria are not satisfied. The requested 
service 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 a Computed Tomography Angiography (CTA) have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a Computed Tomography Angiography (CTA).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that an IRF admission is medically necessary. The Plan 
denied your request. The Plan says you do not meet all the requirements for an IRF admission. 
 
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 the enrollee's documented nursing, medical and rehabilitation 
needs would not be expected to require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation 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 the IRF admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 
You asked the Plan to pre-approve Euflexxa. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug does not meet step therapy criteria. 
 
 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Euflexxa. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has osteoarthritis of the right knee. The documentation does not support that the enrollee has 
tried and failed Synvisc, Synvsic-One, and/or Durolane. The documentation does not support that Synvisc, 
Synvsic-One, and/or Durolane would likely be less effective and/or likely have adverse effects for the enrollee. 
Therefore, the enrollee does not meet criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa.
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 you are deconditioned and unable to participate in or tolerate intensive rehabilitation. You do not require frequent physiatry oversight.

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 Zarxio.

You asked the Plan to pre-approve Zarxio. You say that you disagree with the Plan's denial. The Plan denied your request. The Plan says the enrollee is enrolled in a clinical trial.

The Plan must follow Medicare rules. Medicare rules say that routine costs associated with clinical trials are covered by Original Medicare.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Zarxio have not been met. Therefore, we decided that the Plan does not have to pre-approve Zarxio.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve proton beam radiation therapy (PBRT).

You asked the Plan to pre-approve proton beam radiation therapy (PBRT). You say that the requested proton beam radiation therapy (PBRT) is medically necessary. The Plan denied your request. The Plan says the requested proton beam radiation therapy (PBRT) is not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve proton beam radiation therapy (PBRT). Our reviewer says that the requested proton beam radiation therapy (PBRT) is not medically necessary. Our physician reviewer found there is insufficient prospective, long-term clinical data available to determine whether or not proton beam radiation therapy for prostate cancer is superior, inferior or equivalent to external beam radiation therapy, Intensity-modulated radiation therapy (IMRT), or brachytherapy with regards to safety and efficacy. Recent data shows no significant differences in late (years one, two, and three) patient-reported toxicity outcomes between proton beam therapy and IMRT. The most recent American Urological Association (AUA) and National Comprehensive Cancer Network (NCCN) guidelines state that PBRT offers no clinical advantage over other forms of definitive treatment.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of proton beam radiation therapy (PBRT) have not been met. Therefore, we decided that the Plan does not have to pre-approve proton beam radiation therapy (PBRT).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan of the brain 
(78608). 
 
You asked the Plan to pre-approve a PET scan of the brain. You say that the service is medically necessary. 
The Plan denied your request. The Plan says the enrollee does not meet the diagnostic criteria of both 
Alzheimer's disease and frontotemporal dementia. There is no indication that the exam is being requested in the 
context of a clinical trial. 
 
The Plan follows Medicare rules. Medicare rules say that an FDG PET scan is only covered when there is a 
need to separate a differential diagnosis of frontotemporal dementia and Alzheimers disease. 
 
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 PET scan of the brain. Our reviewer 
says that the enrollee does not meet coverage requirements at this time. Our physician reviewer found the 
enrollee is only noted to have a diagnosis of AD. The records did not otherwise support that the enrollee is 
suspected of meeting diagnostic criteria for both AD and FTD, as required by the NCD for coverage of this 
service. The enrollee is also noted to have other causative factors present (vascular changes). 
 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 PET scan of the brain have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a positron emission tomography (PET) scan of the brain (78608).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ophthalmology services to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve OON services. You say that you are afraid of vision loss. The Plan denied your request. The Plan says there are multiple providers within the network.

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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve ophthalmology 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 IRF case is medically necessary. The Plan denied your request. The Plan says an IRF admission does not meet the Medicare guidelines.

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 review of the available records, the enrollee with history as described above does not meet Medicare coverage criteria for IRF admission. The enrollee is medically stable and does not need
physical medicine and rehabilitation physician supervision 3 times a week in an IRF. No acute rehabilitation nursing needs identified or documented. At the current functional mobility level, the enrollee does not need intensive therapies consisting of at least 3 hours of therapy per day at least 5 days per week with a multidisciplinary approach in an IRF. The enrollee needs physical therapy (PT) and occupational therapy (OT) in an alternate setting. The document does not support necessity for admission to an IRF due to lack of medical or rehabilitation complexity and no nursing needs. While the enrollee may benefit from PT, and OT, the enrollee's rehabilitation needs can be provided in a lower intensity and alternate setting such as in a skilled nursing facility (SNF) or in-home with services or in an SNF.

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 IRF admission and 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 enrollee needs IRF care. The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria for admission to an IRF.

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 that 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.

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.