Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve portable oxygen concentrator.
You asked the Plan to pre-approve portable oxygen concentrator. You say that you would like reconsideration because you are weak and unable to push your walker with the large oxygen tanks. The Plan denied your request. The Plan says you have not tried and failed portable and liquid oxygen tanks.
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 portable oxygen concentrator. Our reviewer says that the medical records provided do not meet the requirements for Medicare coverage. Our physician reviewer found the documentation in the case file does not contain qualifying blood gas study.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of portable oxygen concentrator have not been met. Therefore, we decided that the Plan does not have to pre-approve portable oxygen concentrator.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve non-emergency ambulance transportation (A0428).
You asked the Plan to pre-approve non-emergency ambulance transportation. You say that the enrollee needs to be seen in the office to be properly evaluated and does not have proper transportation. The Plan denied your request. The Plan says the service is not medically necessary.
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. 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 non-emergency ambulance transportation. Our reviewer says that the enrollee does not meet coverage criteria for this service. Our physician reviewer found the record indicates that the enrollee could travel by wheelchair van. The record does not indicate that other means of transportation are contraindicated. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of non-emergency ambulance transportation have not been met. Therefore, we decided that the Plan does not have to pre-approve non-emergency ambulance transportation (A0428).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gelsyn-3.
You asked the Plan to pre-approve Gelsyn-3. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug does not meet step therapy criteria.
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 Gelsyn-3. Our reviewer says that the documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer found the enrollee has primary osteoarthritis of bilateral knees. The documentation does not support that the enrollee has tried and failed viscosupplemental treatments such as Orthovisc and Monovisc. The documentation does not outline contraindications or reasons these medications were not considered or that the plan's required drugs would likely be less effective and/or likely have adverse effects for the enrollee. Therefore, the enrollee does not meet criteria for the requested drug. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Gelsyn-3 have not been met. Therefore, we decided that the Plan does not have to pre-approve Gelsyn-3.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Supartz injections.
You asked the Plan to pre-approve the Supartz injections. You say that this should be approved. The Plan denied your request. The Plan says there is no reason noted that the preferred agents cannot be used.
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 the Supartz injections. Our reviewer says that the requested Supartz is not medically necessary based on step therapy criteria. Our physician reviewer found the enrollee has a diagnosis of Unilateral primary osteoarthritis of the right knee. The documentation is insufficient to support that Orthovisc and Monovisc would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. 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 Supartz injections have not been met. Therefore, we decided that the Plan does not have to pre-approve Supartz injections.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 3 power wheelchair (K0861), tilt and recline (E1007) and elevating leg rests (E1012).
You asked the Plan to pre-approve the Group 3 power wheelchair, tilt and recline and elevating leg rests. You say that you would like reconsideration because the requested wheelchair is medically necessary. The Plan denied your request. The Plan says the member does not meet Medicare coverage criteria for the requested wheelchair.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 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 Group 3 power wheelchair, tilt and recline and elevating leg rests. Our reviewer says that the member's mobility deficit is not corroborated by the physician physical exam that documents normal motor strength, normal gait, and normal coordination.
The documentation does not support that the member has a gait abnormality that impairs MRADLs in the home and is not ameliorated by a walker, cane or manual wheelchair. Our physician reviewer found the documentation is not consistent that this wheelchair with accessories is medically necessary. The documentation also does not consistently support that the members is at high risk for development of a pressure ulcer and is unable to perform a functional weight shift; or utilizes intermittent catheterization for bladder management, or needs a power seating system to manage increased tone or spasticity. 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 Group 3 power wheelchair, tilt and recline and elevating leg rests have not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 3 power wheelchair (K0861), tilt and recline (E1007) and elevating leg rests (E1012).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve MyoPro orthotic device (L8702).
You asked the Plan to pre-approve MyoPro orthotic device. You say that this item is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says current medical literature shows that these services do not have a proven benefit and are considered experimental/investigational.
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 MyoPro orthotic device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the medical records indicate that the enrollee has a history of stroke with left sided weakness. The records provided do not medical records from the ordering physician to establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. The elements of the coverage criteria are not satisfied. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of MyoPro orthotic device have not been met. Therefore, we decided that the Plan does not have to pre-approve MyoPro orthotic device (L8702).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a minimally invasive lumbar decompression (MILD) procedure.
You asked the Plan to pre-approve these services. You say that you are in pain and unable to walk. The Plan denied your request. The Plan says you are not enrolled in an approved study.
The Plan must follow Medicare rules. Medicare rules say that minimally invasive lumbar decompression (MILD) is covered when the beneficiary is enrolled in a Medicare-approved clinical study. We looked at the file and Medicare rules. The file shows that you are not enrolled in an approved clinical study for the MILD procedure. 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 a minimally invasive lumbar decompression (MILD) procedure.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Intracept procedure.
You asked the Plan to pre-approve Intracept. You say that significant clinical and diagnostic patient-specific data supports the medical necessity of this procedure. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because studies have not proven that Intracept is helpful for treatment of the enrollee's condition.
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 Intracept. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the record indicates that the enrollee has chronic low back pain from lumbosacral intervertebral disc degeneration. The provided magnetic resonance imaging (MRI) demonstrates an epidural mass. The MRI does not indicate Modic type changes. The requested device is under investigation as registered for the noted indication.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Intracept have not been met. Therefore, we decided that the Plan does not have to pre-approve the Intracept procedure.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric hospital services for the enrollee. 
 
You asked the Plan to pre-approve inpatient psychiatric hospital services. You say that these services are 
medically necessary for the enrollee. The Plan denied your request. The Plan says that the records received 
show that the enrollee's condition has improved and is no longer a threat to herself or others. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve inpatient psychiatric hospital services. 

Our reviewer says that inpatient psychiatric hospital services are not medically reasonable and necessary for the 
enrollee. It is not expected this enrollee would improve in a reasonable period of time as she does not have 
suicidal or homicidal ideation noted and denied any auditory or visual hallucinations. The patient was 
compliant with treatment while not showing any acute threats to safety. It does not appear medically necessary 
and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of 
care as she does not have dangerousness to herself or others and was compliant with her treatment. Our 
physician reviewer found that the enrollee's condition does not meet Medicare criteria for inpatient psychiatric 
hospital services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric hospital services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve inpatient psychiatric hospital services for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital services provided December 29, 2019 to 
January 2, 2020. 
 
You asked the Plan to pay for the inpatient hospital services. You say that DRG 871 was correctly billed. The 
Plan denied your request. The Plan says DRG 194 is more appropriate for the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 871. 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 pay for the inpatient hospital services. Our reviewer says that the DRG billed is not 
supported in the records. Our physician reviewer found the record indicates that the enrollee was admitted with 
pneumonia and sepsis. Upon admission the enrollee was tachycardic, tachypneic, and had an elevated white 
blood cell count. The documentation indicates the enrollee responded to resuscitation. The record indicates the 
absence of organ dysfunction. DRG 871 is not supported.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided December 29, 2019 to January 2, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a knee scooter.
You asked the Plan to pre-approve a knee scooter. You say that you feel this should be covered because it will assist your mobility after you receive upcoming knee surgery. The Plan denied your request. The Plan says the requested item is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that a knee scooter is not a covered benefit. We looked at the file and Medicare rules. The requested item is not covered. Based on this information, we decided that Medicare rules for coverage of a knee scooter have not been met. Therefore, we decided that the Plan does not have to pre-approve a knee scooter.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the blood bank physician services (86077) provided on March 26, 2021.
You asked the Plan to pay for the blood bank physician services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says CPT code 86077 has an MUE value of 1.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value cannot be paid when the MAI value is 2. In this case, the MUE for CPT code 86077 is 1. The MAI value for this code is 2. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the blood bank physician services have not been met. Therefore, we decided that the Plan does not have to pay for the blood bank physician services (86077) provided on March 26, 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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
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. Our 
physician reviewer found the complexity of your medical and rehabilitation needs do not require an acute 
hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Care at the skilled nursing 
facility level appears to be appropriate in this case. 
 
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation procedures (64635, 64636). 
 
You asked the Plan to pre-approve radiofrequency ablation procedures. You say that the enrollee has not had 
the requested procedure twice in the past year. The Plan denied your request. The Plan says rules for coverage 
for the requested procedure have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that, for each covered spinal region, no more than 
two (2) radiofrequency sessions will be reimbursed per rolling 12 months.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of radiofrequency ablation procedures have not been met. Specifically, the provided medical records 
document that the enrollee has had two radiofrequency ablation procedures performed within the past year. 
Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation procedures (64635, 
64636).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve destruction by neurolytic agent, intercostal nerve (CPT code 64620), for the enrollee.
You asked the Plan to pre-approve the service. You say that the enrollee states their knee is killing them and they find it difficult to walk and sit. You state the enrollee has tried the cortisone shot of which did not work and the provider has said that this is the next step. The Plan denied your request. The Plan says ablation of peripheral nerves to treat pain, destroying nerve tracts with, cryoneurolysis (destruction of a nerve(s) by exposure to cold temperature) to treat pain caused by knee osteoarthritis (a type of arthritis with wearing down of the protective tissue at ends of the bones of knee) is considered investigational. The Plan states there is not enough proof in the medical literature to prove this procedure will benefit knee osteoarthritis. The Plan states the enrollee's records show the enrollee has been diagnosed with left knee osteoarthritis and have tried various treatments (such as heating pad, ace bandage, Voltaren gel and steroid injections) without adequate pain relief.
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 genicular knee nerve ablation remains experimental for use in patients with knee pain. More research is needed to show safety and efficacy.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the service have not been met. Therefore, we decided that the Plan does not have to pre-approve destruction by neurolytic agent, intercostal nerve (CPT code 64620), for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF 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 Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not 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 beyond the last covered date. The enrollee's functional level with weight bearing limitations 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. The enrollee does not require skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis" in a SNF. As a practical matter this enrollee does not require the necessary services on 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 care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.