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

 We decided that the Plan does not have to pre-approve a negative pressure wound therapy (NPWT) electrical pump, stationary or portable for the enrollee.  You asked the Plan to pre-approve the pump. You say that this is medically necessary. The Plan denied your request. The Plan says the records show that the request is for over four months of treatment.  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 pump. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the request for continued use of the E2402 beyond what was approved by the health plan is not medically necessary. The enrollee has used negative pressure wound therapy for four months. The criteria do not support the use of beyond four months (including the time NPWT was applied in an inpatient setting prior to discharge to the home) of a NPWT pump in the treatment of the most recent wound.  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 pump have not been met. Therefore, we decided that the Plan does not have to pre-approve a negative pressure wound therapy (NPWT) electrical pump, stationary or portable for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap) received on July 15, 2021.  You asked the Plan to pay for the Tdap vaccine. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services received are not a covered benefit.  In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the Tdap vaccine. The Plan follows the same rules.      Records do not show that you have been injured or directly exposed to any illness related to the Tdap vaccine. Therefore, we decided that the Plan does not have to pay for the Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap) received on July 15, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve insertion or replacement of spinal neurostimulator pulse generator or receiver, direct or inductive coupling (CPT code 63685) and laminectomy for implantation of neurostimulator electrodes, plate/paddle, epidural (CPT code 63655), for the enrollee.  

You asked the Plan to pre-approve the services. You say that the enrollee was unable to have a successful trial due to having a multilevel fusion with failed back surgery syndrome and that the enrollee will greatly benefit from spinal cord stimulator replacement. The Plan denied your request. The Plan says your request is not medically necessary because the enrollee's records show that they have not had any type of electrical nerve stimulator trial. The Plan states the enrollee's records say that they are improving with psychological/behavioral treatment techniques and thus, this procedure is not a last-resort treatment for the enrollee's pain. The Plan states the enrollee's records do not include formal psychological evaluation by a psychologist or psychiatrist.  

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 services. 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 do not show that the enrollee has had a formal psychiatric evaluation. Criteria for neurostimulator for back pain not 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve insertion or replacement of spinal neurostimulator pulse generator or receiver, direct or inductive coupling (CPT code 63685) and laminectomy for implantation of neurostimulator electrodes, plate/paddle, epidural (CPT code 63655), for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.  You asked the Plan to pre-approve the LTACH services. You say that the medical records provided support the need for LTACH care. The Plan denied your request. The Plan says the guidelines for coverage of LTACH care have not been met. The Plan says that the services needed could be provided in another setting.  The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.  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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee was admitted following a fall resulting from a subdural hematoma. The record indicates that the enrollee continues to require acute care services. The enrollee continues to receive acute care services, and these have not been denied.  The medical record does not indicate that the enrollee requires services that he is not currently receiving but that would be available at the LTACH facility.     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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.  You asked the Plan to pre-approve the LTACH services. You say that the admission to an LTACH is medically necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically necessary.  The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.  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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee continues to receive acute care services, and these have not been denied. The medical record does not indicate that the enrollee requires services that she is not currently receiving but that would be available at the LTACH facility.  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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan.  You asked the Plan to pre-approve PET scan. You say that this PET scan is medically necessary to stage cancer for the enrollee to receive treatment without further delay. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because there is no mention that this scan would be used to determine the extent of the enrollee's tumor.  The Plan must follow Medicare rules. Medicare rules say that PET scans 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 PET scan. Our reviewer says that the enrollee does not meet the Medicare criteria for this PET scan. Our physician reviewer found per guidelines, a PET scan is indicated to assess for distant metastases if positive locoregional nodes are found. There is no imaging or clinical examination to indicate locoregional node involvement. A computed tomography (CT) scan at this point would show involvement of locoregional nodes. This PET scan is not medically reasonable and 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 PET scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve bone marrow aspiration for the enrollee.  You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the clinical value and effectiveness of bone marrow aspirate in the setting of spinal fusion surgery has not been demonstrated in the peer-reviewed literature.  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. Bone marrow aspirate remains experimental in cases of spinal fusion. More research is needed to show safety and efficacy. 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 bone marrow aspiration for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve LTACH services.  You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does not meet criteria.  The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.  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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found you appear to be unstable with continued short-term acute care services to stabilize, that can be safely performed at the current facility. There are no services at the LTACH that you require that are not already available and covered at the current facility. 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150), a periodontal scaling and root planning, four or more teeth per quadrant (D4341) and caries risk assessment and documentation (D0601).  You asked the Plan to pre-approve a comprehensive oral evaluation, a periodontal scaling and root planing and caries risk assessment and documentation. You say that the services requested are medically necessary. The Plan denied your request. The Plan says caries risk assessment and documentation are not listed as a covered benefit. The Plan also says that the enrollee has exhausted his benefit coverage for a comprehensive oral evaluation. The Plan also says a periodontal scaling and root planning is not covered per Medicare guidelines if less than four teeth per quadrant are missing. 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. The Plan covers a comprehensive oral evaluation once every 6 months and a periodontal scaling and root planing with four or more teeth per quadrant once every 24 months.   We looked at the file and Medicare rules. The records show that the enrollee received a comprehensive oral evaluation on October 11, 2021, therefore, the enrollee's benefit for this service has been exhausted. The records also show that the enrollee shows the presence of only 2 teeth and a periodontal scaling and root planing must have a minimum of four or more teeth per quadrant, therefore, the service is not a covered benefit. The records also show that a caries risk assessment and documentation is not a covered benefit with the Plan. Based on this information, we decided that the Plan's rules for coverage of a comprehensive oral evaluation, periodontal scaling and root planing and caries risk assessment and documentation have not been met. Therefore, we decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150), a periodontal scaling and root planning, four or more teeth per quadrant (D4341) and caries risk assessment and documentation (D0601).
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen, infraumbilical panniculectomy (CPT code 15830) and excision, excessive skin and subcutaneous tissue (includes lipectomy), abdomen (eg, abdominoplasty) (includes umbilical transposition and fascial plication) (CPT code 15847), for the enrollee.  You asked the Plan to pre-approve the services. You say that due to the excess skin laxity on the enrollee's body, they report significant sagging around their abdomen. You state the enrollee complains of rashes in their skin folds especially under their abdominal pannus. You state this has interfered with the enrollee's daily activities and ability to fit into clothes. You state the enrollee does not have relief with compression garments and they have a history of back pain. You state removal of the enrollee's excess skin may provide benefit to their back pain. You state weight loss has left the enrollee with excess skin which requires surgical removal to relieve their symptoms of erythema intertrigo and back pain. The Plan denied your request. The Plan says the enrollee does not meet Medicare criteria for panniculectomy.   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 has had significant weight loss and the weight has been stable for more than a year. The record does not indicate that the pannus or panniculus hangs below the level of the pubis. The record indicates that the enrollee has intertrigo and back pain. The record states that no treatment for the intertrigo has been attempted. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen, infraumbilical panniculectomy (CPT code 15830) and excision, excessive skin and subcutaneous tissue (includes lipectomy), abdomen (eg, abdominoplasty) (includes umbilical transposition and fascial plication) (CPT code 15847), for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for drug testing provided on October 20, 2020.  

You asked the Plan to pay for drug testing. You say that providers and insurance companies should work together to make sure patients get efficient treatment. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because the documentation submitted does not support the Place of Service (POS) code billed on this claim.  

The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS).      

We looked at the file and Medicare rules. The sample for this testing was taken in an office setting, therefore the POS code 81 - indicating an independent lab setting - is not an appropriate setting. Based on this information, we decided that Medicare rules for coverage of drug testing have not been met. Therefore, we decided that the Plan does not have to pay for drug testing provided on October 20, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Transcranial Magnetic Stimulation (TMS) services.  You asked the Plan to pre-approve TMS services. You say that this procedure is medically necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met.  The Plan follows Medicare rules. Medicare rules say that TMS services are subject to the criteria listed 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 TMS services. Our reviewer says that the requested TMS services are not medically reasonable and necessary. Our physician reviewer found that the LCD for TMS specifically requires the confirmed diagnosis to be Severe Major Depressive Disorder Single or Recurrent as well as resistance to treatment with pharmacologic agents as evidenced by lack of clinical significant response to 4 trials of pharmacologic agents in the current depressive episode from at least two different agent classes along with concurrent documented psychotherapy. Documentation presented is not specified what medications you have been taking during the present episode of depression. You had been tried on a number of pharmacologic agents from different categories including Vistaril, Prozac, Klonopin, gabapentin, clomipramine, Trazodone, Lamictal, Lithium, Concerta and Klonopin, Adderall, clomipramine, Depakote, Geodon, Latuda, lithium, Prozac, Risperdal, Seroquel, Trintellix, Concerta, Vraylar, Vyvanse, Wellbutrin and Zoloft with little improvement. You did not show documentation of electroconvulsive treatment (ECT) in the past. You have no clear documentation of psychotherapy. You do not meet the LCD requirement for Transcranial Magnetic Stimulation (TMS) in the treatment of Obsessive-Compulsive Disorder, Bipolar Disorder or ADHD.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of TMS services have not been met. Therefore, we decided that the Plan does not have to pre-approve Transcranial Magnetic Stimulation (TMS) 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 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 you do require physical therapy and occupational therapy services but based on the medical records provided you do not require an intensive inpatient rehabilitation therapy program. 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: 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 is not medically necessary.  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 do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do require physical therapy and occupational therapy services but based on the medical records provided you do not require an intensive inpatient rehabilitation therapy program. Medically necessary services can be provided in a different level of care.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.