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

We decided that the Plan has to pre-approve transcatheter aortic valve replacement (TAVR) with prosthetic valve 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 enrollee has not developed severe aortic stenosis.
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 severe symptomatic aortic stenosis with a marked elevated of peak aortic velocity, valve calcification and a echo valve area of 0.5 cm2. He has edema and symptoms of dyspnea and was admitted recently for congestive heart failure after a urologic procedure. Although the cardiac cath valve calculation suggested a possibly less stenotic valve, the cardiac output calculated using the Fick formula is likely somewhat inaccurate in this elderly man, giving a falsely elevated result and likely showing a less stenotic valve by this method. However, the peak doppler velocity on echo is consistent with severe aortic stenosis and the patient has also had symptoms of congestive heart failure and a recent admission for decompensated failure with a normal left ventricular ejection fraction. Given the combination of the echo and clinical findings, it is reasonable to assume he has hemodynamically significant and symptomatic aortic stenosis at this time and would be a reasonable candidate for valve replacement. He has been appropriately evaluated by the structural heart team and found to be a good candidate for TAVR. 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 transcatheter aortic valve replacement (TAVR) with prosthetic valve for the enrollee.
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 is an appropriate candidate for inpatient rehabilitation. The Plan denied your request. The Plan says an IRF admission 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 that the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.
Medical problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your
request. The Plan says unproven and not medically necessary procedures are not covered by Medicare due to
insufficient evidence of efficacy.
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 device. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found current evidence based medical guideline and peer reviewed literature do not fully support the spinal
decompression device procedure over the 'gold standard' of lumbar laminectomy. There is a lack of large
volume, long-term peer-reviewed outcome studies to support the use of this device for this enrollee's medical
condition. FDA indications include implantation of the Superion device at one or two adjacent lumbar levels in
patients with moderate spinal stenosis in whom operative treatment is indicated at no more than two levels,
from L1 to L5. This enrollee has multiple degrees of spinal stenosis, many not at FDA indicated levels of
"moderate" spinal stenosis. (including the planned level of implantation L3-4 and L4-5.) FDA
contraindications include spinal instability, scoliosis and obesity which have not been adequately addressed in
the medical records. There is no discussion of scoliosis of the lumbar spine (with no documentation of Cobb
angle.) 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 Vertiflex Superion
interspinous device at levels L3-L4 and L4-5 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 device have not been met. Therefore, we decided that the Plan does not have
to pre-approve the Vertiflex device for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgery services billed for services provided on March 30, 2021.
You asked the Plan to pay for the services provided. You say that medical records support the services. The Plan denied your request. The Plan says the service cannot be validated.
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 27245 is treatment of intertrochanteric, peritrochanteric, or subtrochanteric femoral fracture; with intramedullary implant, with or without interlocking screws and/or cerclage. We find that CPT code 27245 is not supported in the medical record. In this case, there are insufficient records to show that the service at issue was provided. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the surgery services billed for services provided on March 30, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve medial branch blocks (64493, 64494).
You asked the Plan to pre-approve medial branch blocks. You say that repeat bilateral medial branch blocks are necessary (since it had been some time since your first block in October 2020) before moving on to radiofrequency ablation. The Plan denied your request. The Plan says medical necessity rules for the requested services 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 medial branch blocks. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case.
Our physician reviewer found that you had two successful medial branch blocks and do not need another diagnostic block prior to the radiofrequency ablation (RFA). We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of medial branch blocks have not been met. Therefore, we decided that the Plan does not have to pre-approve medial branch blocks (64493, 64494).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on March 20, 2019.
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 testing is not covered.
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT codes describing the component test results. We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and was not billed as one test under code 81479.
Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on March 20, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex Superion device.
You asked the Plan to pre-approve the device. The Plan denied your request. The Plan says this 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 the device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the Vertilfex device is experimental and more research is needed. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex Superion device.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for an x-ray (72074) provided on April 13, 2021.
You asked the Plan to pay for an x-ray. You say that this is not a duplicate claim. The Plan denied your request. The Plan says that this was previously billed and paid.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Although the Plan states this was previously paid, the case file does not include documentation such as a remittance advice or claim form showing this is the case. Therefore, we decided that the Plan has to pay for an x-ray (72074) provided on April 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an OrCam My Eye Pro low vision aid.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers contact lenses and eyeglasses only. We looked at the file and the Plan's rules. The requested item is a low vision aid that is not covered by Medicare or your supplemental routine vision benefit. Based on this information, we decided that the Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve an OrCam My Eye Pro low vision aid.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral hygiene instructions (D1330) provided on June 18, 2021.
You asked the Plan to pay for the oral hygiene instructions. You say that you are entitled to dental services two times per year, and you received x-rays and a cleaning. You also say that you cannot pay for this service because you are retired. The Plan denied your request. The Plan says this service is not a covered benefit under your dental plan.
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 pay for the oral hygiene instructions (D1330) provided on June 18, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular gene panel provided on March 8, 2021.
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the testing does not meet the requirement for approval.
The Plan must follow Medicare rules. Medicare rules say that diagnostic tests must be ordered by the physician who is treating the enrollee. We looked at the file and the rules. The medical records provided do not indicate the results of the testing would be used in the management of the enrollee's specific medical problem. The medical records do not clearly document the physician's intent for the testing to be performed.
Based on this information, we decided that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that the Plan does not have to pay for the cardiovascular gene panel provided on March 8, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health aide services.
You asked the Plan to pre-approve the services. The Plan denied your request. The Plan says this is not medically necessary.
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or 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 services. Our reviewer says that the requested home health aide services are not medically reasonable and necessary. Our physician reviewer found that based on the medical records provided there is no documentation that the requested services meet the definition of home health aide services as per Sections A, B, C, D & E of Section 50.2 as there is no documentation of a skilled nursing or skilled therapy need or service.
There is no documentation that the home health aide services are medically reasonable and necessary for the treatment of the enrollee's illness or injury by the skilled professional staff as there is no documentation of a skilled nursing or skilled therapy need or service. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pre-approve home health aide services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the chest x-ray rendered on June 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 are not separately payable.
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well. The provider submitted a claim for procedure codes 71045 (chest x-ray, single view) and 71046 (chest x-ray, two views). Code 71045 is a column II code with a modifier indicator of 1 when billed with column I code 71046. Code 71045 was not billed with an appropriate modifier to allow for separate payment.
Therefore, we decided that the Plan does not have to pay for the chest x-ray rendered on June 14, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on May 17, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not approved in advance.
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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the services provided by an out-of-network provider on May 17, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve BRCA testing.
You asked the Plan to pre-approve the testing. The Plan denied your request. The Plan says this is not medically necessary.
The Plan follows Medicare rules. Medicare rules say that BRCA testing is covered for the indications established in the applicable LCD. 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 testing. Our reviewer says that the requested BRCA testing is not medically reasonable and necessary. Our physician reviewer found that Medicare will not cover individuals for genetic testing who lack a personal history of malignancy or have a known deleterious deletion in their family. This enrollee lacks a personal history of cancer and would not meet the LCD coverage criteria. 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 testing have not been met. Therefore, we decided that the Plan does not have to pre-approve BRCA testing.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex Superion interspinous device (CPT code
C1821), for the enrollee.
You asked the Plan to pre-approve the surgery. You say that the enrollee has tried many treatments over the
years including physical therapy, anti-inflammatories such as celecoxib, anti-neuropathics such as gabapentin,
and epidural steroid injections. The enrollee's function has been gradually failing over the past year with
several activities, most specifically walking, as a result of this pain. The Plan denied your request. The Plan
says medical studies have not proven that the use of the product(s) is helpful for treatment of the enrollee's
health problem.
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 surgery. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found the enrollee indicates that the enrollee has chronic low back pain and lumbar spinal stenosis
with neurogenic claudication. The record indicates that the enrollee has multi-level disease, including scoliosis.
The provided record does not indicate the enrollee's pain is relieved in flexion. The record does not state that
the enrollee is not indicated for operative therapy at more than two levels. The Cobb angle is not reported.
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 the surgery have not been met. Therefore, we decided that the Plan does not
have to pre-approve the Vertiflex Superion interspinous device (CPT code C1821), for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an implant supported crown (D6065) provided on May 25, 2021.
You asked the Plan to pay for an implant supported crown. You say that the service should be covered. The Plan denied your request. The Plan says the service at issue is 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 pay for an implant supported crown (D6065) provided on May 25, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance imaging, spinal canal and contents (72148).
You asked the Plan to pre-approve the MRI. You say that you've had multiple back surgeries and operations and is constantly in pain. Medication does not help much, and the pain is getting worse. You want this overturned so you can see what is wrong with your back. The Plan denied your request. The Plan says the records do not support that the enrollee meets the criteria.
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 the MRI. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the criteria for an MRI is not met. Not enough conservative measures for back pain have been tried and failed. Physical therapy is needed.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve magnetic resonance imaging, spinal canal and contents (72148).