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

 We decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT code 22869), for the enrollee.  You asked the Plan to pre-approve the service. You say that you have been treating the enrollee with a treatment plan aimed at goals to achieve pain relief, improved functional capacity, and quality of life. You state you request approval of the denial as the enrollee has multiple medical problems and you feel the Vertiflex procedure is Food and Drug Administration (FDA) approved and has been clinically proven to provide long-term relief. The Plan denied your request. The Plan says the Medicare criteria for reasonable and necessary are not met as it has not been shown to be safe and effective in long term studies and there is a lack of evidence to support that interspinous spacer devices are as safe and effective as the gold standard of 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 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 the enrollee indicates that the enrollee has chronic low back pain and lumbar spinal stenosis with neurogenic claudication. The record indicates that the enrollee has minimal foraminal encroachment and no central stenosis at L4-L5, the level requested for treatment.  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 the service have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT code 22869), for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incisional biopsy of oral tissue-hard (bone, tooth) (CPT
code D7285).
You asked the Plan to pre-approve the dental services. You say that you are having difficulty eating and
chewing. You state you have not been able to wear your dentures in two months and without your dentures it
causes your jaw to be misplaced. The Plan denied your request. The Plan says the service is not a covered
benefit under the plan.
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. This service is not listed in your EOC as a covered benefit; therefore, it
is not covered.
Therefore, we decided that the Plan does not have to pre-approve incisional biopsy of oral tissue-hard (bone,
tooth) (CPT code D7285).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital discharge day management services provided to the enrollee on July 10, 2021.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says Current Procedural Terminology (CPT) code 99239 (1 Unit) remains not supported
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 99239 is "Hospital discharge day management; more than 30 minutes."
We find that CPT code 99239 is not supported in the medical record. Specifically, the records do not document that 31 minutes or more were spent rendering this service. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for hospital discharge day management services provided to the enrollee on July 10, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on April 26, 2021.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says this service should not be unbundled.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 87640 is a column II code to column I code 87641. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services provided to the enrollee on April 26, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive respiratory pathogen panel provided on August 19, 2020.
You asked the Plan to pay for the comprehensive respiratory pathogen panel. You say that this testing is medically necessary. The Plan denied your request. The Plan says the POS code reported is not appropriate.
The Plan must follow Medicare rules. Medicare rules say that for lab services, the POS code must reflect the location in which the sample was taken.
We looked at the file and Medicare rules. In this case, the POS code reported is 11 for an office setting. However, the documentation indicates that the sample was taken in a nursing facility. As such, POS code 11 is not supported. Based on this information, we decided that Medicare rules for coverage of the comprehensive respiratory pathogen panel have not been met. Therefore, we decided that the Plan does not have to pay for the comprehensive respiratory pathogen panel provided on August 19, 2020.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve removal of intact breast implant (CPT code 19328) and peri-implant capsulectomy, breast, complete, including removal of all intracapsular contents (CPT code 19371).
You asked the Plan to pre-approve the services. You say that you are suffering in debilitating pain with your neck, shoulders, arms, back, and chest. You state your primary care physician has been treating you for these problems for years. You state you have been getting constant severe shooting pain in your breasts and nipples, especially the right breast. You state your breasts are looking deformed, the implant sits on top of your chest area and your own breast tissue, which is small, is at the bottom. The Plan denied your request. The Plan says that the medical documentation submitted for review indicates that you have had breast implants and have developed pain in your right breast. The Plan states the documentation indicates that you have a Baker Class II contracture (breast implant is slightly firm) in the right breast and a Baker Class I contracture (breast implant feels soft) in the left breast. However, you do not have an implant infection, implant extrusion (the implant comes through the skin) or implant rupture (a hole or tear in the implant). The Plan states you do not have a Baker Class III contracture (breast is firm and looks abnormal) or Baker Class IV contracture (the breast is hard, painful and looks abnormal).
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 record indicates that you have Baker I and Baker II breast implant contractures with shoulder and neck pain and multiple symptoms of systemic illness consistent with breast implant illness. The record indicates the presence of painful capsular contracture with disfigurement. The elements of the coverage criteria are satisfied. The requested service is 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 been met. Therefore, we decided that the Plan has to pre-approve removal of intact breast implant (CPT code 19328) and peri-implant capsulectomy, breast, complete, including removal of all intracapsular contents (CPT code 19371).
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Contour next test strips, for the enrollee.
You asked the Plan to pre-approve the strips. You say that the enrollee does undergo routine testing every six (6) months and the enrollee is currently out of Contour test strips and they will need them to test their blood sugar. The Plan denied your request. The Plan says the enrollee does not meet the criteria for coverage under Part B for a non-preferred diabetic supply bought at a pharmacy. The Plan states the enrollee can switch to one of their preferred products. The Plan states the medical records submitted do not establish that the Contour Next strips are reasonable and 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 strips. Our physician reviewer found there is no data provided to indicate why the enrollee must use this meter/strips and not one of the preferred brands; there is an insulin pump (medtronic 670g) that uses the contour next system/strips, but we are not told that the enrollee is on a/this pump. 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 strips have not been met. Therefore, we decided that the Plan does not have to pre-approve Contour next test strips, for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; third and any additional level(s) [THIRD LEVEL BILATERAL L4-L5] (CPT code 64495), for the enrollee.  You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your request. The Plan says Medicare states that one to two levels, either unilateral or bilateral, are allowed per session per spine region. The Plan states the need for a three or four level procedure bilaterally may be considered under unique circumstances and with sufficient documentation. The Plan states the submitted medical records do not show unique circumstances necessitating a third level of injections.  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 physician reviewer found according to the coverage criteria, one to two levels, either unilateral or bilateral, are allowed per session per spine region. The need for a three or four-level procedure bilaterally may be considered under unique circumstances and with sufficient documentation of medical necessity on appeal. In this case, the submitted medical records do not document unique circumstances necessitating a third level of MBB injections. The review has determined that the medical records provided do not meet the requirements listed in the LCD for Medicare coverage.  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 the injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; third and any additional level(s) [THIRD LEVEL BILATERAL L4-L5] (CPT code 64495), for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the proton treatment delivery; intermediate (CPT code
77523), for the enrollee.
You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan
denied your request. The Plan says the request is not medically necessary because you have not tried IMRT, the
enrollee is not enrolled in a clinical trial and PBRT has not been proven to be more efficacious than IMRT in
this situation.
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 there are no compelling data to suggest that proton therapy is superior to or more beneficial
than IMRT/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. Our physician reviewer says the decision is unfavorable as they
do not believe the criteria are 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 service have not been met. Therefore, we decided that the Plan does not
have to pre-approve the proton treatment delivery; intermediate (CPT code 77523), for the enrollee.
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 based on IRF criteria. The Plan states home physical therapy or physical therapy at a skilled nursing facility may be covered if requested.
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 lower extremity peripheral vascular disease and gangrene and had lower extremity revascularization and mid foot amputation. 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 enrollee has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive 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 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 IRF care so you can return home at a higher level of functioning. The Plan denied your request. The Plan says it does not appear that you need an intensive program with a team of health care professionals and doctors that specialize in complex medical needs or an interdisciplinary team approach to the delivery of rehabilitation care.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care.
Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 5-Fluorouracil (J9190), Trastuzumab-dkst (Q5114), and Pembrolizumab (J9271).
You asked the Plan to pre-approve 5-Fluorouracil (J9190), Trastuzumab-dkst (Q5114), and Pembrolizumab (J9271). The Plan denied your request. The Plan says this regimen is currently not Food and Drug Administration (FDA) approved for this disease, and the National Comprehensive Cancer Network (NCCN) is also silent on this issue. The Plan also says that the regimen for this indication is experimental.
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 5-Fluorouracil (J9190), Trastuzumab-dkst (Q5114), and Pembrolizumab (J9271). Our reviewer says that the elements of the coverage criteria are not satisfied, and the requested service cannot be recommended.
Our physician reviewer found the record indicates that the prescriber recognizes that this is not a medically accepted indication for the requested regimen. The Food and Drug Administration has not stated that the requested drug is indicated for the enrollee's condition. Our reviewer found that the Medicare approved cancer drug compendia do not contain a supportive citation for the use of the requested drug in the enrollee's clinical situation. Our physician reviewer also found that no literature from Medicare approved cancer journals were submitted for review. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 5-Fluorouracil (J9190), Trastuzumab-dkst (Q5114), and Pembrolizumab (J9271) have not been met. Therefore, we decided that the Plan does not have to pre-approve 5-Fluorouracil (J9190), Trastuzumab-dkst (Q5114), and Pembrolizumab (J9271).
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 based on IRF criteria. The Plan states home
physical therapy or physical therapy at a skilled nursing facility may be covered if requested.
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
thoracolumbar spinal surgery.
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 you have a need for physical and/or occupational therapy, there is no
documentation of a need for an intensive 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.
You asked the Plan to pre-approve the SNF admission. The Plan denied your request. The Plan says your request for an admission to a SNF does not meet the requirements for approval.
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 the SNF admission. Our reviewer says that you do not meet the Medicare criteria for SNF care. Our physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. Our reviewer found that you do not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. Our physician reviewer also found that you do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. We looked at this physician's review, the file, and Medicare rules. Although you have skilled therapy needs, these needs are not on a daily basis. Based on this information, we decided that Medicare rules for coverage of the SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.