Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 10 additional physical therapy (PT) sessions (two sessions have been approved).
You asked the Plan to pre-approve the 10 additional PT visits. You say that it is felt that additional PT is necessary to allow for the enrollee to meet goals. The Plan denied your request. The Plan says the amount of therapy provided thus far should be sufficient. Further therapy is not needed as a maintenance program to prevent deterioration.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 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 10 additional PT visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the member has previously been treated with outpatient therapies and should be independent with a home exercise program. There is no documentation of a recent injury or decline in function. The additional therapy services are not an appropriate duration and frequency for treatment of the member's medical condition and therefore are 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 the 10 additional PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 10 additional physical therapy (PT) sessions (two sessions have been approved).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on May 4, 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 procedure codes 82570 and 83986 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 82570 (assay of urine creatinine), 83986 (assay of pH body fluid, not otherwise specified), and 80307 (presumptive drug testing). Codes 82570 and 83986 are column II codes with a modifier indicator of 1 when billed with column I code 80307.The column II codes were not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on May 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete upper denture (D5110) and complete lower denture (D5120).
You asked the Plan to pre-approve the dentures. You say that your current dentures are only useable if you apply a lot of polygrip. They do not fit well and need to be replaced. The Plan denied your request. The Plan says fixed and removable prostheses, such as dentures, are only covered once every 60 months and only if the existing prostheses are not and cannot be made serviceable. It has not been 60 months since you previously had dentures provided and covered by the Plan. Therefore, the dentures are denied.
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. Replacement of removable and fixed prostheses is covered only if the existing prostheses were inserted at least 60 months prior to the replacement and satisfactory evidence is presented that the existing prostheses are not and cannot be made serviceable.
Though the Plan offers a dental benefit in excess of Medicare coverage, the dentures are requested in a frequency that exceeds what is covered under this benefit. Documentation indicates that you previously had dentures provided less than 60 months before this request. Therefore, we decided that the Plan does not have to pre-approve a complete upper denture (D5110) and complete lower denture (D5120).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an interspinous implant placement (22869).
You asked the Plan to pre-approve the interspinous implant placement. You say that this procedure is medically
necessary. The Plan denied your request. The Plan says this procedure is investigational and non-covered at
this time.
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 interspinous implant placement. Our
reviewer says that the requested services are not considered medically reasonable and necessary in this case.
Our physician reviewer found interspinous devices remain experimental in spinal surgery. More research is
needed to show safety and efficacy of these devices.
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 interspinous implant placement have not been met. Therefore, we decided
that the Plan does not have to pre-approve an interspinous implant placement (22869).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor.
You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections or require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of the monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that due to the enrollee's significant co-morbidities,
extended hospital stay, intensive care unit (ICU) stay, medical complexity and ability to tolerate and benefit
from intensive rehabilitation program the enrollee would benefit from close daily medical supervision at an
IRF. The Plan denied your request. The Plan says the enrollee's records show that it is not reasonable to expect
that the enrollee will be able to fully benefit from the intensity of services of an IRF. The Plan states the
enrollee does not require physician supervision by a rehabilitation doctor at least three (3) days per week. The
Plan states the enrollee does not require an intensive and coordinated interdisciplinary approach to the
enrollee's rehabilitation and their rehabilitation is not complex. The Plan states it is not necessarily reasonable
to expect that the enrollee would be able to actively participate safely in 3 hours of therapy five (5) days a week
or fifteen (15) hours of therapy a week.
The Plan states the enrollee would benefit from skilled therapy after this hospital stay and they can safely
receive the services the enrollee needs in other settings, for example: a skilled nursing facility.
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 nursing, medical and rehabilitation needs does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee
was admitted for anemia and gastrointestinal bleeding. Medical problems are stable. There are no complex
nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the patient has
a need for physical and/or occupational therapy, there is no documentation of a need for an intensive
rehabilitation program. There is not a reasonable expectation that this 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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve prosthetic leg replacement.
You asked the Plan to pre-approve prosthetic leg replacement. You say that the leg is too heavy. The Plan
denied your request. The Plan says this does not meet Medicare criteria as reasonable and necessary needs can
be met with replacement of socket.
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 prosthetic leg replacement. Our
reviewer says that the requested items/services are not considered medically reasonable and necessary in this
case. Our physician reviewer found the review has determined that enrollee status post left above knee
amputation. The enrollee has gained volume in residual limb having poorly fitting socket. No documentation of
change in length of residual limb. Request denied on prior review, as notes do not show that components other
than socket are in disrepair or need to be replaced. The review has determined that the medical records
provided do not meet the requirements listed in the LCD for Medicare coverage. The items/services at issue in
this case are 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 prosthetic leg replacement have not been met. Therefore, we decided that the
Plan does not have to pre-approve prosthetic leg replacement
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a radiofrequency ablation (RFA) of the facet joint
nerves.
You asked the Plan to pre-approve the RFA procedure. You say that the RFA procedure is needed as it will be
helpful in reducing your pain. The Plan denied your request. The Plan says the criteria are not met as the
second MBB procedure did not provide sufficient relief.
The Plan follows Medicare rules. Medicare rules say that a radiofrequency ablation is considered medically
reasonable and necessary for patients who have had at least two (2) medically reasonable and necessary
diagnostic MBBs, with each one providing a consistent minimum of 80% sustained relief of primary (index)
pain.
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 RFA procedure. Our reviewer says
that the criteria for the requested RFA procedure are not met. Our physician reviewer found the enrollee has a
history of low back pain who had an initial MBB with 100% improvement in pain but a second MBB of the
same spinal levels with less than 80% pain relief per provider documentation.
The guidelines indicate that a radiofrequency ablation is considered medically reasonable and necessary for
patients who have had at least two (2) medically reasonable and necessary diagnostic MBBs, with each one
providing a consistent minimum of 80% sustained relief of primary (index) pain (with the duration of relief
being consistent with the agent used). The review has determined that the records did not show the enrollee
has met the coverage criteria. The records do not show that the requested treatment is 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 the RFA procedure have not been met. Therefore, we decided that the Plan does
not have to pre-approve a radiofrequency ablation (RFA) of the facet joint nerves
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 9 additional chiropractor visits.
You asked the Plan to pre-approve the chiropractor visits. You say that the enrollee's quality of life depends on
these visits. His lower back is causing him so much pain. The chiropractic visits are vital to his well being. The
Plan denied your request. The Plan says additional chiropractic visits are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare does not cover chiropractic maintenance
care.
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 chiropractor visits. Our reviewer
says that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found in this case, the record indicates that the enrollee has segmental and somatic
dysfunction of the lumbar region. The record indicates that the enrollee has received 27 treatments to date and
is at baseline. The record does not support acute exacerbation of symptoms. The elements of the coverage
criteria are not satisfied.
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 chiropractor visits have not been met. Therefore, we decided that the Plan
does not have to pre-approve 9 additional chiropractor visits.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve counselor visits to be provided by a counselor.
You asked the Plan to pre-approve counselor visits. You say that you are requesting review of denial of
services. The Plan denied your request. The Plan says outpatient counselor services are not covered by
Medicare. The Plan states there are qualified in-network providers that can provide the services you need.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we
decided that Medicare rules for coverage of counselor visits have not been met. Outpatient counselor services
are not covered by Medicare. Therefore, we decided that the Plan does not have to pre-approve counselor visits
to be provided by a counselor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a multipositional patient support system with integrated
lift and whirlpool walk in tub.
You asked the Plan to pre-approve a multipositional patient support system with integrated lift and whirlpool
walk in tub. You say that you need to make provisions to your home to accommodate your needs. The Plan
denied your request. The Plan says the requested items are not a covered benefit.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose. Medicare rules also state that stair lifts are not covered because they are not primarily medical
in nature.
The items at issue in this appeal does not serve a purpose that is primarily medical in nature. The requested
items are available to the general public and would be helpful even to those who are not sick or injured.
Therefore, we decided that the Plan does not have to pre-approve a multipositional patient support system with
integrated lift and whirlpool walk in tub
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Orthofix MTF Trinity Allograft (CPT code 20930), for the enrollee.
You asked the Plan to pre-approve the allograft. You say that the service is necessary. The Plan denied your request. The Plan says there is insufficient reliable evidence in the form of high-quality peer-reviewed medical literature to establish the safety and efficacy of the requested product for use in cervical fusion procedures. The Plan states this is considered a request for coverage of a non-FDA-approved indication ("off- label" use) which is considered investigational. The Plan states there is no documentation the enrollee is participating in a clinical trial or study. The Plan states the gold standard for cervical spine fusions remains an autograft.
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 allograft. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found trinity allograft remains experimental for use in cervical spine surgery. 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 allograft have not been met. Therefore, we decided that the Plan does not have to pre-approve Orthofix MTF Trinity Allograft (CPT code 20930), for the enrollee.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 8 physical therapy visits (G0151), 8 occupational therapy visits (G0152), and 8 skilled nursing visits (G0299) to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve home health services. You say that there is no staffing available in network. The Plan denied your request. The Plan says the requested services are available 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 home health 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 8 physical therapy visits (G0151), 8 occupational therapy visits (G0152), and 8 skilled nursing visits (G0299) to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services provided to the enrollee on February 3, 2021.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the denied codes remain not supported.
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 code 80307 and Healthcare Common Procedure Coding System (HCPCS) G0483 is not supported in the medical record. Specifically, the place of service on the CMS-1500 form must reflect the location of the patient when the specimen was obtained. The claim reflects a place of service (POS) for a laboratory (POS 81), while the records reflect of place of service of a doctor's office (POS 11). Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for drug testing services provided to the enrollee on February 3, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gel-One 30MG injection (CPT code J3490), for the
enrollee.
You asked the Plan to pre-approve the injection. You say that the injection is necessary. The Plan denied your
request. The Plan says the injection is not necessary.
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 the injection. Our physician reviewer
found the record indicates that the enrollee has a knee pain. The record indicates that x-rays demonstrate
Kellgren-Lawrence grade zero (0) osteoarthritis. The record does not indicate that conservative treatment has
failed. The Food and Drug Administration has not stated that the requested drug is indicated for the enrollee's
condition. The Medicare approved drug compendia do not contain a supportive citation for the use of the
requested drug in the enrollee's clinical situation. 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 injection have not been met.
Therefore, we decided that the Plan does not have to pre-approve Gel-One 30MG injection (CPT code J3490),
for the enrollee
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a knee scooter (crutch substitute).
You asked the Plan to pre-approve a knee scooter. You say that you could not use a wheelchair or crutches
since you are not able to push yourself or lift. The Plan denied your request. The Plan says the requested item is
not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that crutch substitutes are not a covered benefit.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of a knee scooter have not been met. Therefore, we decided that the Plan does not have to pre-
approve a knee scooter (crutch substitute).