Persius/hicric huggingface dataset:
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 the admission. You say that this is medically necessary. The Plan denied your request. The Plan says the request does not show skilled nursing or therapy needs that need to be provided on a daily basis as an inpatient only status. 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 the admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. You do not require skilled nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 the 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: Unfavorable

We decided that the Plan does not have to pre-approve use of Keytruda.

You asked the Plan to pre-approve Keytruda. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because Keytruda is not being requested for a medically accepted indication.

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 Keytruda. Our reviewer says that the enrollee does not meet the Medicare criteria for Keytruda. Our physician reviewer found the requested use of Keytruda is not Food & Drug Administration (FDA) approved for the enrollee's diagnosis. The requested use is not supported by one of the major drug compendia or by clinical research that appears in a Medicare-approved medical journal.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have to pre-approve use of Keytruda.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home visits for the evaluation and management of a new patient to be rendered by the out-of-network (OON) provider.

You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says there are in-network providers available to render the requested services

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 services. Therefore, we decided that the Plan does not have to pre-approve home visits for the evaluation and management of a new patient to be rendered by the out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve neurology office services to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve neurology services. You say that you have been treated by this doctor since your initial diagnosis 16 years ago. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this provider is out-of-network with the Plan and you can be treated by an in-network neurologist.
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 neurology office services to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a spinal cord stimulator (SCS) implantation.

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 medically necessary.

The Plan must follow Medicare rules. Medicare rules say that a spinal cord stimulator (SCS) implantation is
covered when specific criteria are 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 these services. Our reviewer says that
the services are not medically necessary. Our physician reviewer found the enrollee has lumbar spinal stenosis
with neurogenic claudication. She has tried physical therapy and epidural steroid injections. She had a
successful SCS trial and is requesting a permanent implantation. There is no documentation of an evidencebased
indication for SCS placement. There are other evidence-based therapies for the enrollee. The services are
not reasonable or medically necessary 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 these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve a spinal cord stimulator (SCS) implantation.
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 IRF care. The Plan denied your request. The Plan says rules for IRF care have not been met.
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 you were admitted to an acute care hospital for a stroke. Medical problems are stable. There are no complex nursing or rehabilitation needs.
You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 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 you 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient hospital services.
You asked the Plan to pre-approve continued services. The Plan denied your request. The Plan says you are stable and dependent on activities of daily living.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 continued services. Our physician reviewer found that you received inpatient care for an altered mental status, coronavirus, and unspecified convulsions. There is no documentation provided indicating medical necessity for continued inpatient level of care services. Per the documentation, you are stable and require no inpatient diagnostic studies or therapeutic interventions. The review has determined that continued inpatient services are not medically reasonable and 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 continued services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued inpatient hospital services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (44620) provided on April 25, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled code.
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 44620 has a bundled relationship with code 44150 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the services (44620) provided on April 25, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (81230, 81240, 81241, 81249, 81291,
81335, 81408) provided on March 3, 2021.
You asked the Plan to pay for laboratory services. You say that this is supported in the records. The Plan
denied your request. The Plan says the ordering physician states they did not order this testing.
The Plan must follow Medicare rules. Medicare rules say that clinical laboratory services must be ordered and
used promptly by the physician who is treating the beneficiary.
We looked at the file and Medicare rules. The Plan has attested that the physician has confirmed they do not
have the enrollee on file and was not treating the enrollee. The records do not show that the tests at issue were
used by a physician treating the enrollee. Based on this information, we decided that Medicare rules for
coverage of laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for
laboratory services (81230, 81240, 81241, 81249, 81291, 81335, 81408) provided on March 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a SmartPill wireless motility capsule (91112).

You asked the Plan to pre-approve the wireless motility capsule. You say that the testing is medically necessary. The Plan denied your request. The Plan says this service is considered investigational and is 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 wireless motility capsule. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Wireless Motility Capsule (SmartPill, WMC) is FDA approved for evaluation of gastric emptying in gastroparesis, colonic transit in constipation, and evaluation of generalized dysmotility. The device is recognized for assessment of gut dysmotilities by both the American Neurogastroenterology and Motility Society as well as by the American Gastroenterology Association. However, WMC has not been widely accepted as standard of care in clinical practice outside of tertiary care specialty centers and is not more readily available than gastric motility or colon transit testing.

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 wireless motility capsule have not been met. Therefore, we decided that the Plan does not have to pre-approve a SmartPill wireless motility capsule (91112).
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 rehabilitation. The Plan denied your request. The Plan says criteria for admission to the IRF setting have not been met.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable oxygen concentrator (E1392).
You asked the Plan to pre-approve a portable oxygen concentrator. You say that you need a portable oxygen concentrator since you cannot go outside the house without help to carry the current oxygen tank. The Plan denied your request. The Plan says rules for coverage have not been met because the request duplicates the function of previously provided equipment.
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. The file shows that you have an oxygen concentrator (E1390) and a portable oxygen tank (E0431). An oxygen concentrator (E1390) and a portable oxygen tank (E0431) serve the same purpose as a portable oxygen concentrator. Therefore, we decided that the Plan does not have to pre-approve a portable oxygen concentrator (E1392).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a seat lift chair purchased April 5, 2021.

You asked the Plan to pay for this equipment. The Plan says this provider is not an eligible Medicare durable medical equipment provider. The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items provided by vendor who has opted out of the program. This provider is not a Medicare eligible provider. Therefore, we decided that the Plan does not have to pay for a seat lift chair purchased on April 5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the MyoPro G orthosis.
You asked the Plan to pre-approve the MyoPro G orthosis. You say that this device is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says this device is considered experimental/investigational.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the MyoPro G orthosis. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found Based on the medical records provided and current treatment guidelines there is no documentation that the MyoPro G orthosis at issue in this case meets Medicare criteria for medically reasonable and necessary.
The provided records do not document a physical examination by the enrollee's prescribing provider or treatment records from the prescribing provider to document necessity of the device and a vendor generated examination documents a shoulder subluxation which can be a contraindication to use of the device. In addition, current clinical guidelines designate robotic therapy to be of "uncertain utility compared with dose-matched conventional upper limb exercise therapies" with unproven benefit in the home environment. 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 MyoPro G orthosis have not been met. Therefore, we decided that the Plan does not have to pre-approve the MyoPro G orthosis.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a surgical placement of implant (D6010).
You asked the Plan to pre-approve a surgical placement of implant. You say that the service at issue is medically necessary. 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 pre-approve a surgical placement of implant (D6010).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the removal of posterior nonsegmental instrumentation
services coded 22850 and the posterior segmental instrumentation services coded 22844 provided on February
24, 2021.
You asked the Plan to pay for the removal of posterior nonsegmental instrumentation services and the posterior
segmental instrumentation services. You say that you would like the plan to reconsider their denial. The Plan
denied your request. The Plan says the services rendered are not supported by the documentation.
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 find that CPT codes 22850 and 22844 are not supported in the medical record. Specifically, the operative
report did not include documentation of a removal of posterior nonsegmental instrumentation (Harrington rod);
therefore, code 22850 cannot be verified. The operative report did not include documentation of a posterior
segmental instrumentation (pedicle fixation, dual rods with multiple hooks and sublaminar wires); for 13 or
more vertebral segments (Listed separately in addition to code for primary procedure); therefore, code 22844
cannot be verified.
Based on this information, we decided that Medicare rules for coverage of the removal of posterior
nonsegmental instrumentation services and the posterior segmental instrumentation services have not been met.
Therefore, we decided that the Plan does not have to pay for the removal of posterior nonsegmental
instrumentation services coded 22850 and the posterior segmental instrumentation services coded 22844
provided on February 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve alveoloplasty in conjunction with extractions (D7310), surgical extraction (D7210), simple extraction (D7140), and removal of tooth roots (D7250).
You asked the Plan to pre-approve the dental services. You say that the enrollee requires the extraction of their remaining teeth due to periodontal disease. The Plan denied your request. The Plan says the requested services are dental in nature. The Plan also says that routine dental services are not covered under the medical benefit.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement of the enrollee's teeth or the structures directly supporting the enrollee's teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve alveoloplasty in conjunction with extractions (D7310), surgical extraction (D7210), simple extraction (D7140), and removal of tooth roots (D7250).