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

We decided that the Plan does not have to pre-approve Magnetic Resonance Imaging (MRI) of the abdomen (74183).
You asked the Plan to pre-approve the MRI. You say that the MRI is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
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 MRI is not medically necessary. Our physician reviewer found the record indicates that the enrollee has a 1.3 cm benign lipid rich adrenal adenoma on a CT scan in August 2021. The records provided do not indicate the medical necessity or reasonableness of the requested service at his 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 the MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve Magnetic Resonance Imaging (MRI) of the abdomen (74183).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the scaling and root planing (D4341 x 2) provided on May 20, 2021.
You asked the Plan to pay for the dental services. You say that your gums were bleeding badly. You say that you had scaling and root planing performed. You say that this was an emergency. You also say that this should be paid. The Plan denied your request. The Plan says scaling and root planing are not listed as covered services.
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 scaling and root planing are not among those covered under this benefit.
Therefore, we decided that the Plan does not have to pay for the scaling and root planing (D4341 x 2) provided on May 20, 2021.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve a custom seat cushion (E2609).

You asked the Plan to pre-approve the seat cushion. You say that the seat cushion is medically necessary. The Plan denied your request. The Plan says that coverage criteria has not been met.

The Plan follows Medicare rules. Medicare rules say that a custom seat cushion is covered when 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 seat cushion. Our reviewer says that the custom cushion is medically necessary. Our physician reviewer found the documentation indicates that the purpose of this seat cushion is to reduce risk for skin injury. The review has determined that the requested custom seat cushion is 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 seat cushion have been met. Therefore, we decided that the Plan has to pre-approve a custom seat cushion (E2609).

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve an office visit. You say that this request is medically necessary. The Plan denied your request. The Plan says they have in-network providers available to treat the enrollee's condition.
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 an office visit to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee currently meets LTACH admission criteria. The Plan denied your request. The Plan says the enrollee is receiving appropriate in-patient acute care and does not require transfer to an LTACH.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee continues to receive acute care services and these have not been denied. The medical record does not indicate that the enrollee requires services that he is not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is medically stable and will benefit from transfer to an LTACH. The Plan denied your request. The Plan says the enrollee is receiving appropriate in-patient acute care and does not require transfer to an LTACH.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee continues to receive acute care services and these have not been denied. The medical record does not indicate that the enrollee requires services that he is not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a genetic panel (81225, 81226, 81291, 81401) provided on April 12, 2021.
You asked the Plan to pay for a genetic panel. You say that this was medically necessary. The Plan denied your request. The Plan says this was not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. If a laboratory assays 2 or more genes in a patient in parallel, then those 2 or more genes will be considered part of the same panel. A panel constitutes a single procedural service, so 1 code must be submitted for the panel. We find that CPT codes 81225, 81226, 81291, and 81401 are not supported in the medical record. Specifically, these codes were used to report a panel, which should be billed with one code.
Based on this information, we decided that Medicare rules for coverage of a genetic panel have not been met. Therefore, we decided that the Plan does not have to pay for a genetic panel (81225, 81226, 81291, 81401) provided on April 12, 2021.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Monovisc.
You asked the Plan to pre-approve Monovisc. You say that this is medically necessary. The Plan denied your request. The Plan says that this is not supported.
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 Monovisc. Our reviewer says that the requested use of Monovisc is supported in this case. Our physician reviewer found the enrollee is an 86 year old female with bilateral knee pain due to osteoarthritis. X-rays demonstrated advanced arthritic changes with complete loss of medial joint space and osteophyte formation in both knees. The member has had physical therapy and has undergone a steroid injection to the knees. Intra-articular injections with hyaluronic acid are recommended as a possible option for severe osteoarthritis for patients who have not responded adequately to recommended conservative treatments to potentially delay total knee replacement. Intra-articular injection of hyaluronic acid can decrease symptoms of osteoarthritis of the knee; there are significant improvements in pain and functional outcomes with few adverse events. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Monovisc have been met. Therefore, we decided that the Plan has to pre-approve Monovisc.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that LTACH Admission is medically
necessary. The Plan denied your request. The Plan says the enrollee can receive the same services at the current
level of care.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
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 LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found the documentation does not support that the enrollee in this case requires services at
the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no
required medical services identified that are available at the LTACH, that are not available at the current health
care setting being offered by the health plan. 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 LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (K0554) with supply
allowance (K0553).
You asked the Plan to pre-approve a continuous glucose monitor and supplies. You say that the requested items
are a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for continuous
glucose monitors have not been met.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations,
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 assess 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. Based on this information, we decided that Medicare rules for coverage of a
continuous glucose monitor and supplies have not been met. Therefore, we decided that the Plan does not have
to pre-approve a continuous glucose monitor (K0554) with supply allowance (K0553).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the MyoPro 2 Motion G orthotic device (L8702).

You asked the Plan to pre-approve the orthotic device. You say that the enrollee has been referred by his family
practice physician for myoelectric orthotic restoration. The Plan denied your request. The Plan says this item is
considered experimental and investigational. Medical studies have not proven that the device is helpful for the
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. The rules also say that experimental and investigational devices are not covered.

We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the orthotic device have not been met. Therefore, we decided that the Plan does not have to pre-approve
the MyoPro 2 Motion G orthotic device (L8702).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a neurology office visit (99203) to be provided by an
out-of-network (OON) provider.
You asked the Plan to pre-approve a neurology office visit. You say that you do not want to change
neurologists. The Plan denied your request. The Plan says this is 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 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
a neurology office visit (99203) to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a PILD procedure for lumbar spinal stenosis.
You asked the Plan to pre-approve a PILD procedure. You say that the enrollee is participating in a qualifying
clinical study. The Plan denied your request. The Plan says rules for coverage have not been met.
The Plan must follow Medicare rules. Medicare rules say that PILD will be covered by Medicare through CED
for beneficiaries with LSS who are enrolled in an approved clinical study.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of a PILD procedure have not been met. Specifically, you indicated that the enrollee is participating
in a qualifying clinical study. The medical records provided indicate that the enrollee received an interspinous
process decompression procedure on February 3, 2021. An exclusion criterion of the study in which you
indicate the enrollee is participating is an interspinous process decompression procedure within the prior 12
months. Because the enrollee received an interspinous process decompression procedure within the past 12
months, the enrollee is not eligible at this time to participate in the cited clinical study. Therefore, we decided
that the Plan does not have to pre-approve a PILD procedure for lumbar spinal stenosis.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approve acute inpatient hospital care.
You asked the Plan to pre-approve acute inpatient hospital care. You say that the services are necessary. The Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not been met.
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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient admission are met in this case. Our physician reviewer found the record indicates that the treating physician had a reasonable expectation of a length of stay spanning 2 or more midnights. The record indicates that safe discharge has not been arranged at this time. The elements of the coverage rule are satisfied. The requested service is 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 acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pre-approve acute inpatient hospital care.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not have documented skilled nursing needs. You do not have documented skilled therapy needs. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of you condition. Your care needs, as a practical matter, can be provided at a lower level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an interspinous spacer placement (22870, 22869).
You asked the Plan to pre-approve the interspinous spacer placement. You say that the spacer device placement
is medically necessary. The Plan denied your request. The Plan says this procedure is 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 interspinous spacer placement. Our
reviewer says that the requested services are not considered medically reasonable and necessary in this case.
Our physician reviewer found the enrollee has chronic low back pain and lumbar spinal stenosis with
neurogenic claudication. The record indicates that the enrollee has multi-level lumbar disease, including
moderate to severe central stenosis at the levels requested for treatment. The record does not state that the
enrollee has relief in flexion, or that he is not indicated for operative intervention at no more than two levels.
The requested procedure is 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 interspinous spacer placement have not been met. Therefore, we decided
that the Plan does not have to pre-approve an interspinous spacer placement (22870, 22869).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an elective right lumpectomy to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve an elective right lumpectomy. You say that it is necessary for the enrollee to continue receiving care with the OON provider. The Plan denied your request. The Plan says comparable care is available within the Plan's network.

Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan providers available to meet the enrollees' needs. The enrollee's contract with the Plan says that, with few exceptions, enrollees must use contract providers for 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 an elective right lumpectomy. Our reviewer says that it is not medically reasonable and necessary for this procedure to be provided by an OON provider. Our physician reviewer found there is no specific clinical reason to have the surgery performed out of network. The enrollee's care can be appropriately managed within Plan. The review indicates that it is not medically reasonable and necessary for the enrollee to continue receiving care from the OON provider. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an elective right lumpectomy have not been met. Therefore, we decided that the Plan does not have to pre-approve an elective right lumpectomy to be provided by an out-of-network (OON) provider.