Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve MyoPro Orthotic Device (CPT code L8702), for the enrollee.  You asked the Plan to pre-approve the device. You say that the device is necessary. The Plan denied your request. The Plan says the clinical value and effectiveness of MyoPro orthotic device in the setting of unilateral right upper extremity impairment following a brachial plexus injury have not been demonstrated in the peer-reviewed literature.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the MyoPro is considered investigational due to the lack of clinical evidence demonstrating an impact on improved health outcomes. The clinical value, and effectiveness of MyoPro orthotic device in the setting of unilateral right upper extremity impairment following a Brachial Plexus Injury have not been demonstrated in the peer-reviewed literature. The review has determined that the items/services at issue in this case medically are not reasonable or necessary.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the device have not been met. Therefore, we decided that the Plan does not have to pre-approve MyoPro Orthotic Device (CPT code L8702), for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an in-network exception for surgery services to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve an in-network exception. You say that there is a significant risk of stroke waiting for the surgery. The Plan denied your request. The Plan says you may use your out-of-network benefits.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that you receive your care from a provider who is eligible to provide services under Original Medicare.  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. You also have out-of-network benefits. We found no exception that would require the Plan to pre-approve an in-network exception. Therefore, we decided that the Plan does not have to pre-approve an in-network exception for surgery services to be provided by an out-of-network (OON) provider.
Appeal type: Other
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Boost liquid oral nutrition.  You asked the Plan to pre-approve Boost liquid oral nutrition. You say that this is medically necessary for your condition. The Plan denied your request. The Plan says this is not covered under the Plan or Medicare.  The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation.  The items you asked the Plan to pre-approve are considered nutritional supplements. Although these may be appropriate, neither Medicare nor the Plan provides coverage for them. Therefore, we decided that the Plan does not have to pre-approve Boost liquid oral nutrition.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pay for the self-administered drugs provided from August 31, 2021, to September 1, 2021.  You asked the Plan to pay for the self-administered drugs. You say that you would like to be reimbursed for the cost of these drugs because you were not allowed to bring your own to the hospital. The Plan denied your request. The Plan says Part B generally does not pay for self-administered drugs used in the hospital outpatient setting.    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 pay for the self-administered drugs provided from August 31, 2021, to September 1, 2021.   Benefits for the self-administered drugs 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: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Opsumit 10 mg tablet.  You asked the Plan to pre-approve Opsumit. You say that this drug is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says this drug is not covered under the enrollee's medical benefit.  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 Opsumit 10 mg tablet.   Benefits for Opsumit 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: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve porcelain/ceramic retainer crowns for teeth #8 and 11 (D6740) and pontic - porcelain fused to high noble metal for teeth #9 and 10 (D6240).  You asked the Plan to pre-approve porcelain/ceramic retainer crowns for teeth #8 and 11 and pontic - porcelain fused to high noble metal for teeth #9 and 10. You say that the services are necessary. The Plan denied your request. The Plan says the requested services are 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 porcelain/ceramic retainer crowns for teeth #8 and 11 (D6740) and pontic - porcelain fused to high noble metal for teeth #9 and 10 (D6240).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the inpatient hospital services billed with diagnosis related group (DRG) code 193.  You asked the Plan to pay for the inpatient hospital services billed with DRG 193. You say that this claim was coded correctly and should be processed for payment. The Plan denied your request. The Plan says DRG 193 is not supported as the diagnosis of acute respiratory failure with hypoxia.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes.    In this case, you billed the inpatient services provided with secondary diagnosis code, J96.01, defined as Acute respiratory failure with hypoxia. 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 pay for the inpatient hospital services billed with DRG 193. Our reviewer says that the medical records did not support the billing of Acute respiratory failure with hypoxia. Our physician reviewer found that the documentation supported an admission for pneumonia. Our reviewer found that the documentation was inconsistent regarding a diagnosis of acute respiratory failure. Our physician reviewer also found that even though acute respiratory failure is documented in a physician query, supporting medical record documentation was not found within the record.   We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for the inpatient hospital services billed with diagnosis related group (DRG) code 193.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the F2 and F5 gene tests.  You asked the Plan to pre-approve gene tests. You say that these testing services would be beneficial for the enrollee. The Plan denied your request. The Plan says the criteria for coverage have not been met for these gene testing services.  The Plan must follow Medicare rules. Medicare rules say that F2 gene testing and F5 gene testing will be considered medically reasonable and necessary when they are performed for evaluation of venous thromboembolism.  We looked at the file and Medicare rules. In this case, the medical documentation does not confirm that enrollee has the requested medical condition of venous thromboembolism. Based on this information, we decided that Medicare rules for coverage of gene tests have not been met. Therefore, we decided that the Plan does not have to pre-approve the F2 and F5 gene tests.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an office visit (99202) to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve an office visit. You say that OON care is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says there are 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 (99202) 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 spinal surgery.  You asked the Plan to pre-approve spinal surgery. You say that this surgery is medically necessary. The Plan denied your request. The Plan says the criteria for the requested surgery have not been met.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve spinal surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation of adequate conservative measures to include a trail and failure of recent physical therapy for back pain. Therefore, the requested spinal surgery will be considered as not 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 spinal surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve spinal surgery.
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 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 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 review has determined that 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 do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy 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 inpatient mental health care.  You asked the Plan to pre-approve inpatient mental health care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the request is not medically necessary because the records received show that the enrollee's condition has improved, and they are no longer a threat to themselves or others.  The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment.   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 inpatient mental health care. Our physician reviewer found based upon review the records provided for the admission of this enrollee does not meet the criteria for December 21, 2021, forward as this enrollee was not shown to be a danger to themselves or others. The enrollee was not showing any auditory or visual hallucinations and was cooperative/compliant with treatment while not showing any threats the safety. The nurse's notes state the enrollee did not have any auditory or visual hallucinations and did not have any suicidal or homicidal ideation.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient mental health care have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient mental health care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the crown (D2740) provided on June 9, 2021.  You asked the Plan to pay for the crown. You say that you believe this service was partially covered in the past. The Plan denied your request. The Plan says this service is not covered.  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 crown (D2740) provided on June 9, 2021.
Appeal type: Other
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve transcatheter insertion or replacement of permanent leadless pacemaker, right ventricular, including imaging guidance (eg, fluoroscopy, venous ultrasound, ventriculography, femoral venography) and device evaluation (eg, interrogation or programming), when performed (CPT code 33274), for the enrollee.  You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your request. The Plan says the Medicare rules have not been 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 the service. Our physician reviewer found recent guidelines are consistent with the appropriateness of selecting a leadless, as opposed to a traditional, pacemaker, as the leadless system has certain advantages in this setting. This selection should be looked upon as being at the discretion of the treating physician. Therefore, use of a leadless pacemaker would be considered medically appropriate and reasonable in this enrollee's clinical management.  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 transcatheter insertion or replacement of permanent leadless pacemaker, right ventricular, including imaging guidance (eg, fluoroscopy, venous ultrasound, ventriculography, femoral venography) and device evaluation (eg, interrogation or programming), when performed (CPT code 33274), for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ground mileage (A0425) and non-emergent ambulance transport (A0428) provided on September 6, 2021.  You asked the Plan to pay for the ground mileage and non-emergent ambulance transport. You say that the transportation was medically necessary. You also say that there was no mention of needing a prior authorization during the calls with the Eligibility and Benefits Department. The Plan denied your request. The Plan says the medical necessity criteria have not been met.  Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules.   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 pay for the ground mileage and non-emergent ambulance transport. Our reviewer says that the documentation did not support that the ambulance transport on September 6, 2021 was medically reasonable and necessary for the patient. Our physician reviewer found the documentation did not support that other means of transport (such as stretcher van, wheelchair van, taxi, private car, or other type of vehicle) were contraindicated for this patient on September 6, 2021. Our reviewer also found that the documentation did not support that the patient needed the expertise, services and lifesaving and life-sustaining equipment that only a fully equipped ambulance can provide for safe transport on September 6, 2021  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 ground mileage and non-emergent ambulance transport have not been met. Therefore, we decided that the Plan does not have to pay for the ground mileage (A0425) and non-emergent ambulance transport (A0428) provided on September 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve SPRINT PNS.  You asked the Plan to pre-approve the device. You say that the SPRINT PNS is considered an implanted device and therefore, should be eligible for coverage. The Plan denied your request. The Plan says non-implanted peripheral nerve stimulators are not covered by Medicare.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the device. Our physician reviewer found the requesting provider states directly in the appeal that this request for SPRINT PNS is not a trial for a permanent implanted device. The peripheral nerve stimulator is not being employed to assess a patient's suitability for permanent implants. As the SPRINT PNS device request is not for a trial for a permanently implanted device and as the SPRINT PNS electrodes/battery are neither permanent nor surgically implanted, the requested device does not meet NCD criteria for coverage. The review has determined that the SPRINT peripheral nerve stimulator, in this case, is not medically reasonable or necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the device have not been met. Therefore, we decided that the Plan does not have to pre-approve SPRINT PNS.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the Vertiflex procedure.  You asked the Plan to pre-approve the Vertiflex procedure. You say that this procedure is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says this is an experimental/investigational procedure.  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 Vertiflex procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex procedure is experimental. More research is needed to show safety and efficacy of the device.  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 Vertiflex procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex procedure.