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

 We decided that the Plan does not have to pre-approve genicular nerve block (an injection to treat pain in your knee) (CPT code 64454).  You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan denied your request. The Plan says medical studies have not proven that the service(s) or procedure(s) is helpful for treatment of your 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 service. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is limited published, large-scale, long-term peer-reviewed literature that shows the request to be an effective and/or safe treatment for the noted pathology. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the request for genicular nerve block (CPT code 64454) 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 service have not been met. Therefore, we decided that the Plan does not have to pre-approve genicular nerve block (an injection to treat pain in your knee) (CPT code 64454).
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve minimally invasive bilateral percutaneous sacroiliac (SI) joint fusion.  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 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the use of minimally invasive SI joint fusion remains experimental for the treatment of degenerative low back pain. There is no documentation of SI joint instability, fracture, or lesion. The surgery is therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve minimally invasive bilateral percutaneous sacroiliac (SI) joint fusion.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a power wheelchair for the enrollee.  You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied your request. The Plan says this is not covered for use in the nursing home.  The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.   Records show that the wheelchair is being requested for use in a SNF or hospital. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair for the enrollee.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pay for the Skilled Nursing Facility (SNF) services provided on  May 25, 2021 to May 31, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the SNF services. You say that you would like reconsideration because the SNF services were medically necessary. The Plan denied your request. The Plan says the member did not receive prior authorization for the SNF 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 pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.  The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. Additionally, the documentation submitted does not include any clinical information to determine if Medicare criteria for coverage of the SNF services were met. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the Skilled Nursing Facility (SNF) services provided on May 25, 2021 to May 31, 2021 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for segmental gradient pressure pneumatic appliance (CPT code E0673) and pneumatic compression device (CPT code E0675) provided to the enrollee on June 18, 2021.  You asked the Plan to pay for the durable medical equipment (DME). You say that the claim should be paid. The Plan denied your request. The Plan says the DME is not covered.  The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement.  We looked at the file and Medicare rules. The pneumatic compression device and/ or supplies is not covered by Medicare to prevent deep vein thrombosis during and/or following surgery, at home, or in any setting. The enrollee used the equipment in the facility during and/or after surgery. Therefore, we decided that the Plan does not have to pay for segmental gradient pressure pneumatic appliance (CPT code E0673) and pneumatic compression device (CPT code E0675) provided to the enrollee on June 18, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a breast prosthesis mastectomy sleeve (L8010).  You asked the Plan to pre-approve a breast prosthesis mastectomy sleeve. You say that the requested item is a medical necessity for the enrollee. 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 a mastectomy sleeve (L8010) is denied as noncovered since it does not meet the definition of a prosthesis.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a breast prosthesis mastectomy sleeve have not been met. Specifically, the request is for an item that is not covered under the Medicare benefit. Therefore, we decided that the Plan does not have to pre-approve a breast prosthesis mastectomy sleeve (L8010).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a third level of radiofrequency ablation (RFA) services.  You asked the Plan to pre-approve additional RFA services. You say that this is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage have not been met for an additional RFA level.  The Plan follows Medicare rules. Medicare rules say that the need for a three or four-level procedure bilaterally may be considered under unique circumstances and with sufficient documentation of medical necessity on appeal.  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 additional RFA services. Our reviewer says that the requested additional level of RFA services is not medically reasonable and necessary.   Our physician reviewer found the enrollee is a 60-year-old male with a history of chronic pain, chronic back pain, and chronic neck pain due to cervical spondylosis, without myelopathy or radiculopathy. In this case, there are no unique circumstances that would allow an additional level of RFA 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 additional RFA services have not been met. Therefore, we decided that the Plan does not have to pre-approve a third level of radiofrequency ablation (RFA) services.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve percutaneous implantation of neurostimulator electrode array, epidural (CPT code 63650) and fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures (epidural or subarachnoid) (CPT code 77003), for the enrollee.  You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your request. The Plan says your request is not medically necessary because the enrollee's records do not show that a spinal cord stimulator is considered only as a late resort for the enrollee's pain and the enrollee does not have a condition for which this treatment 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 physician reviewer found the enrollee does not have an evidence-based indication for a SCS trial. The request is deemed 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve percutaneous implantation of neurostimulator electrode array, epidural (CPT code 63650) and fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures (epidural or subarachnoid) (CPT code 77003), for the enrollee.
Appeal type: Other
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve F2 gene genetic testing (81240).  You asked the Plan to pre-approve F2 gene genetic testing. You say that this genetic testing service is medically necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met.  The Plan must follow Medicare rules. Medicare rules say that CPT Code 81240 F2 gene testing is not considered to be medically necessary. Based on this information, we decided that Medicare rules for coverage of F2 gene genetic testing have not been met. Therefore, we decided that the Plan does not have to pre-approve F2 gene genetic testing (81240).
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung cancer screening.  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 you do not meet the criteria for coverage.  The Plan must follow Medicare rules. Medicare rules say that LDCT for lung cancer screening is covered for beneficiaries aged 55-77 years who meet specific criteria.  We looked at the file and Medicare rules. The file shows that you are 80 years old. 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 low dose computed tomography (LDCT) scan for lung cancer screening.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the home visit provided by an out-of-network provider on September 7, 2021.  You asked the Plan to pay for the home visit. You say that the treatment received was medically necessary and the medical records justify the reason for the member stay. The Plan denied your request. The Plan says this provider is not a network provider with the Plan and 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 did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the home visit provided by an out-of-network provider on September 7, 2021.
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 you have a list of issues. You state you need to be in a hospital setting and you are still recovering from Coronavirus (COVID-19) due to respiratory failure. You state you had secondary sepsis and acute renal failure. You state you currently have a peg feeding tube within your stomach and have protein malnutrition. The Plan denied your request. The Plan says the stay is not medically necessary based on IRF criteria. The Plan states you can safely receive the services you need in other settings, for example: a skilled nursing facility (SNF) or home with home health services.  The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for respiratory failure and Coronavirus (COVID-19) pneumonia. 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 you have 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 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 IRF admission and services.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Trulance.  You asked the Plan to pre-approve Trulance. You say that the medication is necessary. The Plan denied your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage.  The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Trulance.   Benefits for Trulance may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve homemaker service (CPT code S5130) and chore services (CPT code S5120).  You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your request. The Plan says chore services are not a Medicare covered benefit.  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 the services have not been met. Your 2022 EOC says services not covered: Custodial care is personal care that does not require the continuing attention of trained medical or paramedical personnel, such as care that helps you with activities of daily living, such as bathing or dressing. This includes chore services. Furthermore, Medicare guidance says status code "I" Not valid for Medicare purposes. Medicare uses another code for reporting of and payment for these services. Therefore, we decided that the Plan does not have to pre-approve homemaker service (CPT code S5130) and chore services (CPT code S5120).
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for diagnostic services provided on August 29, 2021.  You asked the Plan to pay for diagnostic services. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they 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 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 diagnostic services provided on August 29, 2021.
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 the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.  The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of 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 coronary artery bypass grafting. 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 enrollee 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: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the bone replacement graft (D7953) provided on April 13, 2021 and the bone replacement graft (D7953) and cone beam CT capture (D0364) provided on May 11, 2021.  You asked the Plan to pay for the bone replacement grafts (D7953) and cone beam CT capture (D0364). You say that the bone grafts are required for restoration of extracted teeth. You say that the claims should be honored to continue supporting necessary dental maintenance. The Plan denied your request. The Plan says the services are not covered benefits.  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 bone replacement graft (D7953) provided on April 13, 2021 and the bone replacement graft (D7953) and cone beam CT capture (D0364) provided on May 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a provisional crown - further treatment or completion of diagnosis necessary prior to final impression (D2799).  You asked the Plan to pre-approve a provisional crown. You say that your dentist says this service is necessary. The Plan denied your request. The Plan says this service is not covered under your benefits.  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 provisional crown - further treatment or completion of diagnosis necessary prior to final impression (D2799).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a guided tissue regeneration (D4266) to be provided by a participating provider.  You asked the Plan to pre-approve a guided tissue regeneration. You say that you would like the Plan to pay for this dental work. The Plan denied your request. The Plan says D4266 is not a covered service.  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 guided tissue regeneration (D4266) to be provided by a participating provider.