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

 We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the neck/spine without contrast (72141).  You asked the Plan to pre-approve an MRI. You say that this imaging service is medically necessary.  The Plan denied your request. The Plan says there is no evidence to support the medical necessity of the requested MRI. The enrollee has mild superficial soft tissue swelling without neurological deficits and no evidence of infection.  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 an MRI. Our reviewer says that the requested service is not medically necessary. Our physician reviewer found that prior evaluations with a surgeon did not recommend surgical correction of the cervical spine. No spinal tenderness was noted, slight soft tissue swelling was noted on examination without evidence of a mass, and overlying skin changes. The enrollee appeared well at her baseline; vitals were normal. MRI cervical spine has been requested. An x-ray has not been performed first, and there are no red flag signs on examination or history to warrant more immediate advanced imaging. Therefore, without sufficient support for this request, the MRI will be considered 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 an MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the neck/spine without contrast (72141).
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve peri-implant capsulectomy, breast, complete, including removal of all intracapsular contents (CPT code 19371), insertion of breast implant on same day of mastectomy (CPT code 19340), implantation of biologic implant (eg, acellular dermal matrix) for soft tissue reinforcement (CPT code 15777), and removal of intact breast implant (CPT code 19328), for the enrollee.  You asked the Plan to pre-approve the services. You say that the procedures should be covered due to the enrollee having a ruptured implant in the left breast, and to make it more symmetrical. The Plan denied your request. The Plan says the appeal request is fifty (50) years post mastectomy. The Plan states the complaint noted is the want for symmetry, which falls under cosmetic, and as stated in the letter, the enrollee did receive funds for the recall on the implant, and chose to keep the funds, and not have the implant replaced.  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 physician reviewer found the records indicate that the enrollee has a ruptured left implant and requires removal and replacement. The record indicates that augmentation of the right breast implant is desired. The record indicates that the breast augmentation is not being performed because of a new cancer diagnosis but rather for symmetry purposes. The elements of the coverage criteria are not satisfied. The requested service is not recommended.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pre-approve peri-implant capsulectomy, breast, complete, including removal of all intracapsular contents (CPT code 19371), insertion of breast implant on same day of mastectomy (CPT code 19340), implantation of biologic implant (eg, acellular dermal matrix) for soft tissue reinforcement (CPT code 15777), and removal of intact breast implant (CPT code 19328), for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve compression stockings identified with code A6530  You asked the Plan to pre-approve the compression stockings. You say that these compression stockings are medically necessary. The Plan denied your request. The Plan says the requested compression stockings are not covered by Medicare.  The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are noncovered because they do not meet the statutory definition of a surgical dressing. Although this item may be appropriate for your use, 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 pre-approve compression stockings identified with code A6530
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve proton beam therapy.  You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found there is no clear evidence that proton beam therapy for prostate cancer offers any clinical advantage over other forms of definitive radiation therapy. It is not routinely recommended for prostate cancer outside of a prospective clinical trial or registry. There is no compelling data to suggest that proton beam therapy is superior to or beneficial than intensity modulated radiation therapy (IMRT) or image guided radiation therapy (IGRT). The generally accepted standard of care for prostate cancer is to only offer proton beam therapy on clinical trials, and to not routinely offer it to patients. The services are 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve proton beam therapy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to provide coverage for this equipment.   You asked the Plan to provide coverage for FreeStyle Libre 14-Day Sensors for a Continuous Glucose Monitor. You say that your physician wants this to be recognized for hypoglycemia use and not diabetes. The Plan denied your request. The Plan says Medicare coverage criteria for the requested equipment are not met.  The Plan must follow Medicare rules. Medicare rules say that this equipment is only covered when all five of the listed criteria are met. Based the medical records, you do not meet all of the criteria required. Therefore, we decided that the Plan does not have to provide coverage for FreeStyle Libre 14-Day Sensors for a Continuous Glucose Monitor.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.  You asked the Plan to pre-approve SNF services. You say that you are not ready to stand up. You need to be in the facility and is making some progress. The Plan denied your request. The Plan says the Medicare criteria for continued SNF level of coverage were not met.  The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing and skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis and does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Step-Therapy
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Prolia.  You asked the Plan to pre-approve Prolia. You say that this drug is medically necessary. The Plan denied your request. The Plan says step therapy criteria have not been met.  Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.  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 Prolia. Our reviewer says that the requested drug is not medically reasonable and necessary for the enrollee's condition. Our physician reviewer found the enrollee has a diagnosis of stage 4 prostate cancer. The enrollee is osteopenic. The Plan requires a history of osteoporotic fracture or has tried or cannot use zoledronic acid before they will approve the requested drug. The patient has not satisfied the criteria. In addition, there is no evidence that the Plan's required drug(s) likely be less effective and/or likely have adverse effects for the enrollee.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve CPAP device and supplies (CPT code(s): A7035, A7036, A4604, A7039, A7045, A7046, A7028, A7029, A7030, A7031, A7032, A7033, A7038).  You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your request. The Plan says your doctor asked for replacement supplies (Replacement supplies for your positive airway pressure (PAP) machine). The Plan states this is to help treat your sleep disorder (obstructive sleep apnea). The Plan states this request is not approved because your doctor did not send notes that show you use your device for at least four (4) hours per night on 70 percent of nights. The Plan states these replacement supplies are not 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 DME. Our physician reviewer found continued CPAP and supplies are not medically necessary. The only medical records are a Compliance Report for November-December 2021, that does not meet Medicare criteria of at least four (4) hrs/day for at least 70% of days. Actual use is only 17% of days with at least 4 hrs. There are no records indicating that the compliance issue is being addressed. The device is not being used enough to be effective. The denial is upheld.  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 DME have not been met. Therefore, we decided that the Plan does not have to pre-approve CPAP device and supplies (CPT code(s): A7035, A7036, A4604, A7039, A7045, A7046, A7028, A7029, A7030, A7031, A7032, A7033, A7038).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the advanced care planning provided on May 24, 2021.  You asked the Plan to pay for the services provided. You say that the physician provided medically necessary services in good faith. The Plan denied your request. The Plan says an appropriate modifier was not billed.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code.  The file shows that CPT code 99497 was billed along with code 99223. We looked at the file and the rules. We find that CPT code 99497 may be eligible for separate payment when billed with this code pair. The claim information does not show that code 99497 was billed with a modifier suitable for payment. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the advanced care planning provided on May 24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM).  You asked the Plan to pre-approve a therapeutic CGM. You say that this device is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage of the device have not been satisfied.  The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan.    We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a therapeutic CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve implants (D6010) for teeth # 5, 11, 13, 19, 20 and 21.  You asked the Plan to pre-approve dental implants. You say that you cannot chew properly. You say that this has led to acid reflux. You also say that these services are necessary. The Plan denied your request. The Plan says dental implants are 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 dental implants are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve implants (D6010) for teeth # 5, 11, 13, 19, 20 and 21.
Appeal type: Step-Therapy
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Injectafer (J1439).  You asked the Plan to pre-approve Injectafer. You say that this drug is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says step therapy criteria have not been met.  Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.  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 Injectafer. Our reviewer says that the requested drug is not medically reasonable and necessary. Our physician reviewer found the enrollee is a 76-year-old female with iron deficiency anemia and a prior adverse reaction to a Venofer infusion. The Plan requires a trial of drug Infed and documentation of intolerance or inadequate response to oral iron before they will approve the requested drug, Injectafer. Based on the medical records provided the patient has not tried and failed the required drug and records do not document intolerance or inadequate response to oral iron. In addition, there is no indication that the plan's required drug would likely be less effective and/or likely have adverse effects for the patient.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Injectafer have not been met. Therefore, we decided that the Plan does not have to pre-approve Injectafer (J1439).
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the Grafix PRIME skin graft for the enrollee.  You asked the Plan to pre-approve these services. You say that this is medically necessary. The Plan denied your request. The Plan says that records do not show that the enrollee has failed at least a 30 day period during organized comprehensive conservative therapy.  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 these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. The provided records do not clearly show full efforts with treating this patient's diabetes which is the foundation of treating diabetic ulcers. There was no mention of strict lifestyle medicine and medical treatment to manage the diabetes. Also, there was only a very short duration of trial of wound care, where at least a 30-day duration of treatment with failure is needed to be considered for grafting. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve the Grafix PRIME skin graft for the enrollee.
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 are not strong enough to move on your own, and you need inpatient rehab as soon as possible for the best chance at recovery. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. The necessary services can safely be provided in an alternate setting, such as a skilled nursing facility.  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. 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: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for continuous glucose monitor supplies (K0553) provided on September 15, 2021.  You asked the Plan to pay for continuous glucose monitor supplies. You say that this was billed with a correct diagnosis. The Plan denied your request. The Plan says this was not billed with a required modifier.  The Plan must follow Medicare rules. Medicare rules say that modifier KX or KS must be added to the codes on every claim submitted for therapeutic CGM devices (code K0554) and supply allowances (code K0553).  We looked at the file and Medicare rules. The billed code K0553 was not billed with a modifier as required by Medicare rules. Based on this information, we decided that Medicare rules for coverage of continuous glucose monitor supplies have not been met. Therefore, we decided that the Plan does not have to pay for continuous glucose monitor supplies (K0553) provided on September 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve use of enteral formula (B4152).  You asked the Plan to pre-approve enteral formula. You say that the requested item is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage for enteral nutrition have not been met.  The Plan must follow Medicare rules. Medicare rules say that enteral nutrition is covered for an enrollee who requires feedings via an enteral access device.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of enteral formula have not been met. Specifically, the provided medical records do not support that the enrollee requires feedings via an enteral access device. Therefore, we decided that the Plan does not have to pre-approve use of enteral formula (B4152).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the hip x-ray (73502) provided on March 1, 2021.  You asked the Plan to pay for the hip x-ray. You say that you would like reconsideration because this is for the professional component of the billed service. The Plan denied your request. The Plan says these services are considered included in the Skilled Nursing Facility stay.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.   We find that CPT code 73502 is not supported in the medical record. Specifically, the record indicates that the member was in a Part A covered Skilled Nursing Facility stay. Separate payment may only be made for the professional component of radiology services rendered to member's in a Part A covered stay. CPT code 73502 was not billed with a modifier to indicate that this service represents the professional component. Based on this information, we decided that Medicare rules for coverage of the hip x-ray have not been met. Therefore, we decided that the Plan does not have to pay for the hip x-ray (73502) provided on March 1, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Methylprednisolone.  You asked the Plan to pre-approve Methylprednisolone. The Plan denied your request. The Plan says this is not a covered 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 Methylprednisolone.