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

 We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the arm.  You asked the Plan to pre-approve CT scan. You say that it is very important that this CT scan gets done. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because current evidence does not support this scan in this clinical scenario.  The Plan must follow Medicare rules. Medicare rules say that CT scans 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 CT scan. Our reviewer says that you do not meet the Medicare criteria for this CT scan. Our physician reviewer found your treating provider desires to use this scan to enable use of the Arthrex Virtual Implant Positioning (VIP) system which is an online pre-operative planning system offering reusable patient-specific surgical instrumentation for total shoulder arthroplasty and reverse shoulder arthroplasty. This request is not considered 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 CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the arm.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve incontinence supplies.  You asked the Plan to pre-approve incontinence supplies. You say that this is medically necessary. The Plan denied your request. The Plan says this was not authorized by the primary care physician.  The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable.   While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Surgery
Decision: Unfavorable

  We decided that the Plan does not have to pre-approve an implantable automatic defibrillator.  You asked the Plan to pre-approve implantable automatic defibrillator. You say that the enrollee meets criteria for this. The Plan denied your request. The Plan says the denial of authorization for this procedure is correct, because the enrollee does not meet the Medicare criteria  The Plan follows Medicare rules. Medicare rules state that implantable automatic defibrillators may be covered for enrollees who meet certain criteria.  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 implantable automatic defibrillator. Our reviewer says that the enrollee does not meet the Medicare criteria for an implanted cardioverter defibrillator (ICD). Our physician reviewer found tricuspid regurgitation is not a contraindication for use of a transvenous ICD unless a prosthetic tricuspid valve is present, and guidelines for implantation of a subcutaneous ICD reflect this. They outline various criteria, none of which this patient meets. As to the issue of the medical necessity of a (non-subcutaneous) ICD, the patient's medical therapy was modified on 10/21/21 and, as such, has not been assessed for a 90-day period of treatment. Guidelines reflect a requirement that optimal medical management for three months be administered, as clinical improvement may occur and if ejection fraction rises to a level above 35%, the need for a defibrillator implant can be avoided. Thus, in the absence of this documentation, implantation of an ICD would not be considered 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 implantable automatic defibrillator have not been met. Therefore, we decided that the Plan does not have to pre-approve an implantable automatic defibrillator.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the genetic testing provided on May 12, 2021, by an OON provider.  You asked the Plan to pay for the genetic testing. You say that it is the responsibility of the ordering physician to request prior authorization. You say you do not have direct access to request authorization. The Plan denied your request. The Plan says no prior authorization was obtained.  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 genetic testing provided on May 12, 2021, by an OON provider.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve computed tomography (CT) scan of the thorax (71250).  You asked the Plan to pre-approve CT scan of the thorax. You say that these imaging services are medically reasonable and necessary for the enrollee's condition. 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 CT scans 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 CT scan of the thorax. Our reviewer says that the requested CT scan is not medically reasonable and necessary. Our physician reviewer found that the record indicates that the enrollee has a cough and underwent CT scan in August 2021 that demonstrated a bronchocele. No further work-up has been performed. The provided records do not indicate the medical necessity or reasonableness, as defined by Medicare rules, of the requested service at this time. 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 CT scan of the thorax have not been met. Therefore, we decided that the Plan does not have to pre-approve computed tomography (CT) scan of the thorax (71250).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the Intracept Procedure.  You asked the Plan to pre-approve the Intracept Procedure. You say that you would like reconsideration because this procedure is safe, efficacious, and effective. The Plan denied your request. The Plan says the requested procedure is experimental.  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 Intracept Procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this procedure is experimental and more research is needed to show its safety and efficacy.       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 Intracept Procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the Intracept Procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a portable ventilator.  You asked the Plan to pre-approve a portable ventilator. You say that the enrollee's best medical interest to continue average volume-assured pressure support (AVAPs) management in order to reduce risk of readmission to the hospital and worsening of his medical condition. The Plan denied your request. The Plan says the enrollee does not meet the criteria for coverage.  The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD.  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 a portable ventilator. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the record indicates that the enrollee has acute on chronic respiratory failure from chronic obstructive pulmonary disease. The enrollee was hypercarbic and responded to treatment with the AVAPS setting.  The provided primary source documentation does not contain sufficient detailed information in the medical record to justify the treatment selected. The enrollee could be treated with a bilevel positive airway pressure (BiPAP) machine with AVAPS capability.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a portable ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a portable ventilator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the eye exam and refraction with an out-of-network provider.  You asked the Plan to pre-approve the eye exam and refraction with an out-of-network provider. The Plan denied your request. The Plan says out of network services are not a covered benefit when services are available within your plan.  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 the eye exam and refraction with an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the surgical implant placements (D6010).  You asked the Plan to pre-approve the surgical implant placements (D6010). You say that the procedures are medically necessary due to the patient not being able to properly eat which is causing malnutrition, chronic anemia and severe weight loss. You say that the patient tried dentures, but implants will give the patient more support and improve their medical state. The Plan denied your request. The Plan says the service is not a covered benefit.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.    Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the surgical implant placements (D6010).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for a refraction (92015) provided on July 21, 2021.  You asked the Plan to pay for a refraction. You say that this should be covered. The Plan denied your request. The Plan says this is not a covered service under Medicare or the Plan.  The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and eyewear.   The services you asked the Plan to pay for are considered routine vision services or eyewear. Therefore, we decided that the Plan does not have to pay for a refraction (92015) provided on July 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a continued referral to an out-of-network  You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says there are no 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 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 continued referral to an out-of-network
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve home health nursing services for evaluation and management of the plan of care, each 15 minutes (G0162), and skilled nursing care (G0299).  You asked the Plan to pre-approve the home health services. You say that it has been 3 weeks since you requested a nurse to do wound care and to bathe you. You say that you informed your doctor that you are waiting on a request. You also say that your doctor should have sent all of the necessary documents. The Plan denied your request. The Plan says a physician order has not been received for the requested home health services.  The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.  We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the home health services have not been met. Specifically, the file does not show there is a physician order for the requested home health services. Therefore, we decided that the Plan does not have to pre-approve home health nursing services for evaluation and management of the plan of care, each 15 minutes (G0162), and skilled nursing care (G0299).
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the lower back.  You asked the Plan to pre-approve the MRI. You say that the records provided support the need for the requested MRI. The Plan denied your request. The Plan says there is no clinical documentation that supports the need for the requested MRI.  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 criteria for coverage have not been met. Our physician reviewer found the enrollee has a diagnosis of proximal muscle weakness and back pain. The record does not indicate the occurrence of acute injury. The record indicates increased tone in upper and lower extremities and the presence of cogwheeling. The requested service is not medically necessary and reasonable for the diagnosis and treatment for the enrollee's clinical condition 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 the MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the lower back.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.  You asked the Plan to pre-approve IRF care. You say that you need more intensive therapy that what you are able to get at home. The Plan denied your request. The Plan says you do not meet the Medicare criteria for admission to an IRF.  The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that 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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve sacroiliac (SI) joint radiofrequency ablation (RFA).  You asked the Plan to pre-approve SI RFA. You say that the enrollee is going through a lot of pain. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because SI RFA is considered experimental/investigational.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SI RFA. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found according to the literature, sacral lateral nerve branch blocks and/or ablations/neurotomies for the diagnosis and/or treatment of sacroiliac joint mediated pain is considered experimental and investigational. Studies completed say that this procedure does not improve outcomes compared to standard treatment of SI joint pain. Radiofrequency ablation for denervation, whether performed using traditional, cooled, or pulsed radiofrequency, is considered investigational and therefore, 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 SI RFA have not been met. Therefore, we decided that the Plan does not have to pre-approve sacroiliac (SI) joint radiofrequency ablation (RFA).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for microsurgery (procedure code 69990)  You asked the Plan to pay for the services. You say that this is medically necessary. The Plan denied your request. The Plan says this code cannot be unbundled.  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 69990 is not supported in the medical record. Specifically, CPT 69990 is not able to be reported separately from the approved spinal surgery codes. 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 microsurgery (procedure code 69990)
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve cardiac rehabilitation. You asked the Plan to pre-approve cardiac rehabilitation. You say that the enrollee has cardiac issues for which cardiac rehab is ordered and feels this is needed. The Plan denied your request. The Plan says there is no evidence that the enrollee meets one of the criteria for this program.  The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary cardiac rehab programs. The services must be provided in a doctor's office or an outpatient hospital setting.   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 cardiac rehabilitation. Our reviewer says that the services are not medically necessary. Our physician reviewer found the records show that you have a history of hypertension and previous abdominal aortic aneurysm repair. At a follow-up visit, the enrollee was described as feeling quite well, lost 15 pounds, and for the first time in 8 years was able to walk a mile without exertional symptoms. On exam, only trace edema was noted. The enrollee has been referred for phase II cardiac rehabilitation and instructed her to make a follow-up office appointment in three months. The cardiac rehab 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 cardiac rehabilitation have not been met. Therefore, we decided that the Plan does not have to pre-approve cardiac rehabilitation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a shower or tub bench.  You asked the Plan to pre-approve a shower or tub bench. You say that a shower or tub bench is medically necessary. The Plan denied your request. The Plan says a shower or tub bench is not covered by Medicare.  The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower or tub bench may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower or tub bench.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve medical nutrition therapy.  You asked the Plan to pre-approve the services. You say that this is not medically necessary. The Plan denied your request. The Plan says there is no evidence of diabetes or kidney disease.  The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services only for enrollees with renal disease or diabetes.   Records do not show that you suffer from renal disease or diabetes. Therefore, we decided that the Plan does not have to pre-approve medical nutrition therapy.