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

We decided that the Plan does not have to pre-approve the remaining 4 requested visits for ongoing
chiropractic treatment.

You asked the Plan to pre-approve 4 additional chiropractic visits. You say that you are attempting to stop pain
medication and chiropractic treatments have helped to reduce your pain. The Plan denied your request. The
Plan says your progress has stalled.

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is
manual manipulation of the spine to correct a subluxation.

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 4 additional chiropractic visits Our
reviewer says that the service is not medically necessary. Our physician reviewer found the record indicates
that the enrollee has chronic back pain. The provided records do not indicate by physical examination or x-ray
that the enrollee has a subluxation. 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 4 additional chiropractic visits have not been met. Therefore, we decided that
the Plan does not have to pre-approve the remaining 4 requested visits for ongoing chiropractic treatment.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve retainer crowns (D6740) for teeth # 11, 13 and 15, pontics (D6245), for teeth # 12 and 14, and an application of desensitizing medicament (D9910) for teeth # 11, 13 and 15.
You asked the Plan to pre-approve the dental services. You say that the services should be covered. The Plan denied your request. The Plan says retainer crowns are not listed as covered services. The Plan says pontics are not listed as covered services. The Plan says desensitizing medicament are not listed as covered services either.
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 retainer crowns (D6740) for teeth # 11, 13 and 15, pontics (D6245), for teeth # 12 and 14, and an application of desensitizing medicament (D9910) for teeth # 11, 13 and 15.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Rituxan Hycela.

You asked the Plan to pre-approve the requested drug. The Plan denied your request. The Plan says maintenance treatment is not supported.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use. 

The file shows that Rituxan every 2 months as maintenance therapy was requested. 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 drug. Our physician reviewer found that the requested use of Rituxan Hycela is not FDA-approved for the enrollee's diagnosis. The use is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. The requested use is not listed as not indicated, not supported or not recommended in any of the compendia. The review has determined that the documentation does not support that the requested drug is safe and effective and otherwise reasonable and necessary for this 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 the requested drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Rituxan Hycela.
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 enrollee is a fall risk. The Plan denied your request. The Plan says the enrollee is unable to safely participate in the intensity of services of 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 physician reviewer found that the enrollee was admitted to the acute care hospital for seizures, non-surgical management of a subarachnoid hemorrhage, and urinary tract infection. Her medical problems are stable. There are no complex nursing needs. She does not require treatment by multiple therapies in an intensive rehabilitation therapy program. 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.
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 home ventilator.

You asked the Plan to pre-approve the requested ventilator. The Plan denied your request. The Plan says a pulmonary function test and sleep study is needed.

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 the requested ventilator. Our physician reviewer found that the enrollee has a diagnosis of severe COPD. He was recently hospitalized with acute respiratory failure. Hypercarbia was suggested by a venous blood gas, but the records do not document an arterial blood gas. He was successfully treated with BiPAP. Certain BiPAP devices can provide the AVAPS-AE mode of support that has been ordered. Medicare does not cover a home ventilator when used as BiPAP. There is no documentation of BiPAP failure when stable. Therefore, a home ventilator is not medically
necessary for this 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 the requested ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a home ventilator.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an outpatient visit (G0463) provided December 10, 2020.

You asked the Plan to pay for the outpatient visit. You say that the services were medically necessary. The Plan denied your request. The Plan says the claim did not include a valid diagnosis code.

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 G0463 is not supported in the medical record. Specifically, Z80.9 is not listed as a valid principle diagnosis code for this service. Based on this information, we decided that Medicare rules for coverage of the outpatient visit have not been met. Therefore, we decided that the Plan does not have to pay for an outpatient visit (G0463) provided December 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair expandable controller, harness, electrical connection, and power seat elevation feature.

You asked the Plan to pre-approve power wheelchair components. You say that you need these components. The Plan denied your request. The Plan says the denial of authorization for these wheelchair components is correct.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. Medicare rules say that a power seat elevation feature is non-covered by Medicare
because it is not primarily medical in nature. 

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 power wheelchair components. Our reviewer says that the requested expandable controller, harness, and electrical connection are not considered medically reasonable and necessary in this case. Our physician reviewer found records indicate you have a 4/5 upper extremity strength and are independent with self-feeding and grooming, thus indicating that your upper extremity strength and function are adequate to control the wheelchair's power options with their own switches. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of power wheelchair components have not been met. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair expandable controller, harness, electrical connection, and power seat elevation feature.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to provide an interspinous spacer procedure.

You asked the Plan to provide insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level (22869) and insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; second level (List separately in addition to code for primary procedure) (22870). You say that the enrollee has suffered for too long and it has greatly impacted her quality of life. The Plan denied your request. The Plan says there is lack of evidence to support interspinous spacer devices as safe and effective as the gold standard of surgical decompression.

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 provide insertion of interlaminar/interspinous process stabilization/distraction device. Our physician reviewer found 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 request for Vertiflex Superion interspinous spacer device at L3-L4 and L4-L5 is not medically reasonable or necessary.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level (22869) and insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; second level (List separately in addition to code for primary procedure) (22870) have not been met. Therefore, we decided that the Plan does not have to provide an interspinous spacer procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a K3 foot for a prosthesis.

You asked the Plan to pre-approve a K3 foot. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested item is not medically necessary.

The Plan follows Medicare rules. Medicare rules say that K3 feet are only covered for certain indications. The documentation must support clinical assessments of rehabilitation potential based on the specific classification levels.

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 K3 foot. Our reviewer says that the documentation does not support that the requested item is medically reasonable or necessary. Our physician reviewer found you have a left lower extremity amputation and require a lower extremity prosthesis. There is no documentation that you meet Medicare criteria for the requested K3 prosthetic foot. The provided records do not include documentation from the treating or prescribing provider confirming that you are or have the potential to be a K3 level ambulator. Therefore, you do not meet criteria for the requested item. 

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 K3 foot have not been met. Therefore, we decided that the Plan does not have to pre-approve a K3 foot for a prosthesis.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services (22849) provided October 6, 2020.

You asked the Plan to pay for the surgical services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does 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. 

In this case, the CPT Code Manual definition of code 22849 is a reinsertion procedure. 

We find that CPT code 22849 is not supported in the medical record. Specifically, no technical operative report was submitted to support the procedure billed. Based on this information, we decided that Medicare rules for coverage of the surgical services have not been met. Therefore, we decided that the Plan does not have to pay for surgical services (22849) provided October 6, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (87496, 87498, 87798, 87486, 87541, 87581, & 87640) provided September 9, 2020.

You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the billed services.

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 codes 87496, 87498, 87798, 87486, 87541, 87581, & 87640 are not supported in the medical record. Specifically, the place of service on the claim (81, laboratory) does not match the place of service in the records (11, office setting). Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (87496, 87498, 87798, 87486, 87541, 87581, & 87640) provided September 9, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy.

You asked the Plan to pre-approve physical therapy. You say that you feel these services should be covered. The Plan denied your request. The Plan says the requested services are not medically necessary.

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 physical therapy. 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 you had previously been treated with outpatient therapies and should be independent with a home exercise program. There is no documentation of a recent injury. The additional therapy services are not an appropriate duration and frequency for treatment of your medical condition. Therefore, you do not meet criteria for the requested physical therapy 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 physical therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve physical therapy.
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 enrollee has so many medical complexities that the need for close monitoring and staff support is beyond what a skilled nursing facility could provide in this community during the pandemic. The Plan denied your request. The Plan says based on Medicare guidelines, your request for an IRF admission does not meet the requirements for approval.

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 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 is weak with trouble mobilizing and ambulating. Medical problems are otherwise 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 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 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) provided on February 7, 2021.

You asked the Plan to pay for ambulance response and treatment, no transport. You say that you declined transport to the hospital because the paramedics checked you and said things looked okay. The Plan denied your request. The Plan says the ambulance benefit is a transportation benefit and without a transport there is no payable service.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. 

The ambulance company did not provide transport services on February 7, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) provided on February 7, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the electroencephalogram coded 95955 and the short-latency somatosensory evoked potential study coded 95927 provided on October 8, 2020.
You asked the Plan to pay for the electroencephalogram and the short-latency somatosensory evoked potential study. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable as 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 find that CPT codes 95955 and 95927 are not supported in the medical record. Specifically, the technical report did not include documentation of an electroencephalogram (EEG) during nonintracranial surgery (carotid surgery); therefore, code 95955 cannot be verified. The technical report did not include documentation of a short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in the trunk or head; therefore, code 95927 cannot be verified. Based on this information, we decided that Medicare rules for coverage of the electroencephalogram and the short-latency somatosensory evoked potential study have not been met.
Therefore, we decided that the Plan does not have to pay for the electroencephalogram coded 95955 and the short-latency somatosensory evoked potential study coded 95927 provided on October 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on April 26, 2021.

You asked the Plan to pay for a comprehensive oral evaluation. You say that you had to go to another provider. The Plan denied your request. The Plan says the service is a covered benefit, but you have exceeded the frequency limit of one every 3 Plan years.

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. 

We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a comprehensive oral evaluation have not been met. Specifically, the record shows that you had exceeded the frequency limit prior to this service on January 13, 2021. Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on April 26, 2021.