Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bilateral pars injections.
You asked the Plan to pre-approve the requested services. You say that the injection is diagnostic to determine if spondylolysis is the source of the enrollee's pain. The Plan denied your request. The Plan says the enrollee is not treating the enrollee for facet joint syndrome.
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 requested services. Our physician reviewer found that the enrollee has diagnoses of bilateral sacroiliitis, lumbar spondylolysis, bilateral chronic L5 pars fractures with spondylolisthesis at L5-S1 level, neuroforaminal stenosis of the lumbosacral spine, sacroiliac joint syndrome, and bilateral L5-S1 lumbosacral radiculopathy. The enrollee has failed extensive conservative care including activity modification, medications, and physical therapy. The requested injections are limited to those with low-back pain that is non-radicular. Therefore, the requested service 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 requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve bilateral pars injections.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional physical therapy (PT) sessions.
You asked the Plan to pre-approve the additional PT services. You say that while the enrollee has made progress, there are some areas in which further therapy would be helpful, which would not be achievable from a home exercise program. The Plan denied your request. The Plan says the enrollee's short-term goals have been met. There is not a medical need for ongoing PT.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.
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 additional PT services. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the patient has had prior extensive therapy and the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or by or under the supervision of a therapist. The patient has been instructed in a home exercise program. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain the patient's current condition or to prevent or slow further deterioration. 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 additional PT services have not been met. Therefore, we decided that the Plan does not have to pre-approve additional physical therapy (PT) sessions.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a raised toilet seat.
You asked the Plan to pre-approve a raised toilet seat. You say that a raised toilet seat is necessary for safety. The Plan denied your request. The Plan says a raised toilet seat is not covered by Medicare.
The Plan covers all items that Medicare covers. Medicare rules state that raised toilet seats are not covered because they are not primarily medical in nature. While a raised toilet seat 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 raised toilet seat.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lumbar radiofrequency ablation.
You asked the Plan to pre-approve destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, single facet joint (64635) and destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional facet joint (List separately in addition to code for primary procedure) (64636). You say that you need the procedures. The Plan denied your request. The Plan says you have had this same procedure two times within the past year which is the limit. The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. You have had two procedures in January 2021. Based on this information, we decided that Medicare rules for coverage of destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, single facet joint (64635) and Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional facet joint (List separately in addition to code for primary procedure) (64636) have not been met. Therefore, we decided that the Plan does not have to pre-approve lumbar radiofrequency ablation.
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 this is medically necessary. The Plan denied your request. The Plan says the enrollee would have much difficulty tolerating 3 hours of therapy a day.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.
The enrollee was admitted for thoracic spine surgery (tumor decompression, laminectomy and fusion). Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve SNF admission. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested admission 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 admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the documentation does not support that you require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment in a SNF. The documentation does not reveal evidence of complex wound care or other skilled nursing SNF need. Your functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment in a SNF. You do not require skilled nursing or skilled therapy services (or a combination of these services) on a daily basis in a SNF. 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 admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the bone replacement grafts. 
 
You asked the Plan to pre-approve the bone replacement grafts. 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 
bone replacement grafts.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the compression stockings identified with code A6533 that were issued on May 3, 2021.
You asked the Plan to pay for the compression stockings. You say that the compression stockings were medically necessary. The Plan denied your request. The Plan says this type of compression stocking is not covered.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6533 are noncovered because they do not meet the statutory definition of a surgical dressing.
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for the compression stockings identified with code A6533 that were issued on May 3, 2021.
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 enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services. The
enrollee's care needs can be met 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 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment with Keytruda (J9271).
You asked the Plan to pre-approve Keytruda. You say that the requested treatment is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met because the requested treatment is off-label and not medically supported.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Keytruda. Our reviewer says that the requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that the requested use of Keytruda is not approved by the Food and Drug Administration (FDA) for the enrollee's diagnosis. The requested drug is not FDA-approved as monotherapy for clear cell renal carcinoma. The use is not supported by one of the major drug compendia or by clinical research that appears in a Medicare-approved medical journal.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have to pre-approve treatment with Keytruda (J9271).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral for out-of-network services at the in-network benefit level.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says out-of-network benefits can be utilized.
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 services at the in-network benefit level. There are out-of-network benefits available. Therefore, we decided that the Plan does not have to pre-approve a referral for out-of-network services at the in-network benefit level.
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 would like reconsideration because the IRF services are medically necessary. The Plan denied your request. The Plan says you do not meet Medicare coverage criteria.

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. Ourphysician reviewer found there are no complex nursing or rehabilitation needs. 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve office visits to be provided by an out-of-network provider.
You asked the Plan to pre-approve out-of-network office visits. You say that the enrollee has been seen at this facility for several years. The Plan denied your request. The Plan says the requested facility 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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve office visits to be provided by an out-of-network provider.
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 would like reconsideration because the IRF
services are medically necessary. The Plan denied your request. The Plan says the member does not meet
Medicare coverage criteria for the IRF services.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found there are no complex nursing or rehabilitation needs. There is no documented need
for a intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this member 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 acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that you would like reconsideration because the IRF services are medically necessary. The Plan denied your request. The Plan says the member does not meet Medicare coverage criteria for the IRF services.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found there are no complex nursing or rehabilitation needs. There is no documented need
for a intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this member 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a medical alert device.
You asked the Plan to pre-approve a medical alert device. You say that you had a stroke and need this device to call for help if needed. The Plan denied your request. The Plan says medical alert devices are not covered by Medicare.
The Plan covers all items that Medicare covers. Medicare rules state that precautionary equipment is not covered. While an alert system or device 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 medical alert device.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on November 24, 2020 and billed under code 49084.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the records provided do not support the services billed.
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 asked our coder 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 this service. Our reviewer says that Medicare billing criteria are not met. Our reviewer found the documentation does not support this procedure as separate from the primary more comprehensive procedure that was reported and paid for same date of service. Therefore, CPT 49084 would be inclusive to the more comprehensive procedure CPT 44310 and should not be reported separately.
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of physician services have not been met. Therefore, we decided that the Plan does not have to pay for physician services provided to the enrollee on November 24, 2020 and billed under code 49084.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services (75710) provided October 1, 2020.
You asked the Plan to pay for the radiology services. You say that the services were medically necessary. The Plan denied your request. The Plan says the code billed is not eligible for separate payment.
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 75710 is not supported in the medical record. Specifically, this service is inclusive to the primary procedure billed (37229-RT). Based on this information, we decided that Medicare rules for coverage of the radiology services have not been met. Therefore, we decided that the Plan does not have to pay for radiology services (75710) provided October 1, 2020.