Persius/hicric huggingface dataset:
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 want to get better and need assistance of a rehabilitation facility before you get worse, you are recovering from Coronavirus, you cannot breath and you do not have energy. 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 your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You have a past medical history of Coronavirus infection August 29, 2021, treated with outpatient monoclonal antibodies and a diagnosis of carcinoma in situ of the breast. You are living at home with progressive weakness. 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 the documentation does support a need for physical and/or occupational therapy, there is no documented need for a 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 IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone marrow aspirate (CPT code 20939), for the enrollee.
You asked the Plan to pre-approve the service. You say that you are requesting review of denial of services. The Plan denied your request. The Plan says the clinical value and effectiveness of bone marrow aspirate in the setting of spinal fusion surgery 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 service. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found bone marrow aspirate remains experimental in spinal surgery. More research is needed to show 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 service have not been met. Therefore, we decided that the Plan does not have to pre-approve bone marrow aspirate (CPT code 20939), for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the neuroplasty and or transposition of the median nerve at the carpal tunnel.
You asked the Plan to pre-approve the neuroplasty and or transposition of the median nerve at the carpal tunnel. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested 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 the neuroplasty and or transposition of the median nerve at the carpal tunnel. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee was being treated for primary osteoarthritis left wrist. The enrollee presented with left wrist pain that radiates both up and down to the enrollee's fingers and arm. The enrollee notes symptoms of numbness and tingling as well as night pain on the left side, that the enrollee states are similar to the right sided symptoms the enrollee had on the right prior to carpal tunnel release. The wrist pain is significantly more debilitating for the enrollee.
Exam reveals tenderness both dorsally and volarly over the left distal radioulnar joint. The enrollee has significant tenderness with pronosupination of the wrist. The enrollee has approximately 10 degrees of supination and 5 degrees of pronation before the enrollee states that the range of motion is too painful to continue. Distally, the hand is neurovascularly intact. The enrollee is able to give a thumb up, A-okay, cross his fingers. Sensation to light touch is intact. However, detailed documentation is not evident regarding trial and failure of recent, reasonable and comprehensive less invasive conservative care measures prior to the requested carpal tunnel release. In addition, electrodiagnostic testing is not provided to corroborate pathology. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines. Therefore, the enrollee does not meet criteria for the requested services. 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 neuroplasty and or transposition of the median nerve at the carpal tunnel have not been met. Therefore, we decided that the Plan does not have to pre-approve the neuroplasty and or transposition of the median nerve at the carpal tunnel.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the catheter implant to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the catheter implant. You say that you are out-of-state and cannot return to the service area. The Plan denied your request. The Plan says the provider is out-of-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. The medical record does not indicate you cannot travel back to the in-network area. Therefore, we decided that the Plan does not have to pre-approve the catheter implant 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 cataract surgery to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve cataract surgery to be provided by an OON provider. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are neither emergent nor urgent to seek out-of-network care. The Plan says there are in-network providers available that can provide the requested cataract surgery.
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 cataract surgery to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Octagam 10%, IVIG (CPT code J1568), for the enrollee.

You asked the Plan to pre-approve the Octagam IVIG. You say that the enrollee is in a current crisis and is worsening. 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 Octagam IVIG. Our physician reviewer found the records do not show that the enrollee had tried and failed azathioprine. Based on the lack of documentation of a failed trial of azathioprine, this request for Octagam IVIG does not meet criteria. 

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 Octagam IVIG have not been met. Therefore, we decided that the Plan does not have to pre-approve Octagam 10%, IVIG (CPT code J1568), for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve spine surgery and inpatient hospital care (CPT code(s): 22558, 22845, 22853, 22612, 63047, 22842, 95940, and 95926), for the enrollee.

You asked the Plan to pre-approve the services. You say that the enrollee has a symptomatic disc protusion at L4-5. You state the enrollee has failed conservative management including transforaminal injections at L4-5. The Plan denied your request. The Plan says the clinical value and effectiveness of a lumbar ALIF/PLIF procedure in the absence of central or foraminal stenosis and/or the presence of segment instability 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 services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found criteria for spinal fusion surgery not met. There is no documented spine instability, fracture, or tumor. Fusion surgery not needed. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met.

Therefore, we decided that the Plan does not have to pre-approve spine surgery and inpatient hospital care (CPT code(s): 22558, 22845, 22853, 22612, 63047, 22842, 95940, and 95926), for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on June 15, 2020.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the claim was billed incorrectly.

The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. 

We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the drug testing rendered on June 15, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.

You asked the Plan to pre-approve SNF 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 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 there are no identifiable skilled nursing
service needs. There are identifiable skilled therapy service needs. You do not require skilled nursing or
therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for an
inpatient basis in a SNF setting.

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 SNF care.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve services to destroy a nerve in the lower back (CPT
code(s): 22899 and C9752) for the enrollee.

You asked the Plan to pre-approve the services. You say that the science supporting this treatment is far greater
than many other procedures that the Plan will provide coverage for. The Plan denied your request. The Plan
says there are not enough studies to show Intracept is safe and effective to treat back pain.

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 services. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found the nerve ablation procedures for low back pain including the Intracept procedure are
experimental. More research is needed to show 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 services have not been met. Therefore, we decided that the Plan does not
have to pre-approve services to destroy a nerve in the lower back (CPT code(s): 22899 and C9752) for the
enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve multilevel fusion and inpatient hospital care (CPT code(s): 22634, 22842, 22853, 20930, 63047, 63048 and 61783), for the enrollee.
You asked the Plan to pre-approve the services. You say that the enrollee has failed conservative treatment. The Plan denied your request. The Plan says lumbar fusion for treatment of multiple level degenerative disc disease is considered experimental/investigational/unproven.
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 services. 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 spinal instability, fracture, lesion, or major deformity. Multilevel fusion not needed. Criteria not met. 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 multilevel fusion and inpatient hospital care (CPT code(s): 22634, 22842, 22853, 20930, 63047, 63048 and 61783), for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the office visit to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve the office visit. You say that you cannot interrupt your established care because this provider is keeping track your medications. The Plan denied your request. The Plan says the provider is out-of-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. The records provided for review do not show that the services at issue are urgent or emergent. Therefore, we decided that the Plan does not have to pre-approve the office visit 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 inpatient services for a knee replacement.
You asked the Plan to pre-approve inpatient services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested 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 inpatient services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the provided records do not support the medical necessity and reasonableness, as defined by Medicare rules, of the requested service for your condition. The record does not document that the treating physician has a reasonable expectation of a length of stay spanning two or more midnights. You may be sufficiently admitted for observation for the requested services. Therefore, you do not meet criteria for the
requested inpatient services. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient services for a knee replacement.
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 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 Coronavirus 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 the documentation does support a need for physical and/or occupational therapy, there is no documented need for a 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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve therapeutic bilateral RFA of the medial branch nerves of
L3-4, and L4-5, and L5-S1 (CPT code(s): 64635 and 64636) for the enrollee.

You asked the Plan to pre-approve the services. You say that the enrollee's pain has returned, and you have
requested a repeat therapeutic bilateral RFA of the medial branch nerves of L3-4, and L4-5, and L5-S1. The
Plan denied your request. The Plan says the Medicare rules have not been met.

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. The request for repeat bilateral
RFA of the lumbar/sacral region does not meet the requirements for coverage because the enrollee has already
had two (2) RFA sessions within this 12-month period. Therefore, we decided that the Plan does not have to
pre-approve therapeutic bilateral RFA of the medial branch nerves of L3-4, and L4-5, and L5-S1 (CPT code(s):
64635 and 64636) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve outpatient mental health services to be provided by a
licensed professional counselor (LPC).
You asked the Plan to pre-approve outpatient mental health services to be provided by an LPC. You say that
you would like the Plan to reconsider your request. The Plan denied your request. The Plan says the requested
provider is ineligible to bill Medicare.
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is
not enrolled in the Medicare program. The rules also say that a licensed professional counselor is not eligible to
enroll in Medicare.
Review of the file and Medicare records indicates that the provider at issue is not eligible to be enrolled in the
Medicare program. Therefore, we decided that the Plan does not have to pre-approve outpatient mental health
services to be provided by a licensed professional counselor (LPC).