Persius/hicric huggingface dataset:
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 services are medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
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 records show the enrollee still requires acute care services. The enrollee's needs are met in the current setting. The LTACH does not offer any services that the enrollee cannot receive in the current acute care 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 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the neurostimulator implantation (63650).
You asked the Plan to pre-approve the neurostimulator implantation (63650). You say that the member has a
long history of chronic back pain since 1952 and has undergone extensive conservative management. You say
that she is a qualified candidate for this procedure and the denial should be reconsidered. The Plan denied your
request. The Plan says medical necessity has not been established; therefore, this service is not covered.
The Plan must follow Medicare rules. Medicare rules say that dorsal column stimulators may be covered as
therapies for the relief of chronic intractable pain under certain circumstances.
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 neurostimulator implantation
(63650). Our reviewer says that the criteria for the neurostimulator has not been met. Our physician reviewer
found that the patient has chronic back pain and does not have an established diagnosis that is covered for
stimulator placement.
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 neurostimulator implantation (63650) have not been met. Therefore, we
decided that the Plan does not have to pre-approve the neurostimulator implantation (63650).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the specialized prosthetic foot cover.
You asked the Plan to pre-approve the specialized prosthetic foot cover. You say that you would like reconsideration because the requested cover is medically necessary. The Plan denied your request. The Plan says there is no documentation of unusually harsh environmental situations for which a standard prosthetic cover (L5704) would be insufficient.
The Plan follows Medicare rules. Medicare rules say that 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 specialized prosthetic foot cover. Our reviewer says that there is no documentation that the requested specialized lower limb prosthetic cover meets Medicare criteria for medical necessity in comparison to the standard cover. Our physician reviewer found the records do not document your exposure to such a harsh environment that the standard cover would be inadequate to protect the prosthesis. 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 specialized prosthetic foot cover have not been met. Therefore, we decided that the Plan does not have to pre-approve the specialized prosthetic foot cover.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bilateral balloon sinuplasty of maxillary, frontal, and sphenoid sinuses.
You asked the Plan to pre-approve bilateral balloon sinuplasty of maxillary, frontal, and sphenoid sinuses. You say that the requested bilateral balloon sinuplasty of maxillary, frontal and sphenoid sinuses is medically necessary. The Plan denied your request. The Plan says the requested bilateral balloon sinuplasty of maxillary, frontal and sphenoid sinuses is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve bilateral balloon sinuplasty of maxillary, frontal, and sphenoid sinuses. Our reviewer says that the requested bilateral balloon sinuplasty of maxillary, frontal and sphenoid sinuses is not medically necessary. Our physician reviewer found based on available clinical documentation, the request for balloon sinuplasty is not medically reasonable and necessary.
Although the enrollee did report nasal obstruction and facial pressure for at least one-year, clinical documentation did not indicate whether the nasal drainage was clear or purulent, which is a key distinction made in the definition of Chronic rhinosinusitis (CRS) according to the 2015 American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNSF) clinical practice guideline on adult sinusitis. Computed tomography (CT) findings on December 29, 2021, showed that the ostiomeatal units were patent bilaterally, and the radiology report explicitly stated, "no evidence of sinusitis." Although the progress note from January 7, 2022, stated that there was "3mm thickening bilaterally" in the sinus CT study, mucosal thickening alone is considered nonspecific by the AAO-HNSF sinusitis guideline, and mild mucosal thickening of the ethmoid air cells furthermore would not be addressed by balloon sinuplasty of the maxillary, frontal, and sphenoid sinuses. Moreover, the expert panel on the 2018 AAO-HNSF clinical consensus statement on balloon sinus dilatation achieved consensus on statement #2 ("Balloon dilation is not appropriate for patients with sinonasal symptoms and a CT that does not show evidence of sinonasal disease"). Given the above findings in available clinical documentation, the use of balloon sinuplasty does not appear to be indicated for the enrollee's symptoms. In summary, balloon sinuplasty is not medically reasonable and necessary to manage the enrollee's condition. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of bilateral balloon sinuplasty of maxillary, frontal and sphenoid sinuses have not been met. Therefore, we decided that the Plan does not have to pre-approve bilateral balloon sinuplasty of maxillary, frontal, and sphenoid sinuses.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xopenex.
You asked the Plan to pre-approve Xopenex. You say that you would like the Plan to reconsider their denial.
The Plan denied your request. The Plan says Xopenex is not covered under the enrollee's Medicare Part B
benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Xopenex.
Benefits for Xopenex may be available under Medicare Part D. Contact the Plan that administers Part D
benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the neurolytic agent destruction (64624).
You asked the Plan to pre-approve the neurolytic agent destruction (64624). You say that the nerve blocks with
serial follow up was decided as the member was not a surgical candidate. You say that this will provide longer
pain relief and is medically necessary. The Plan denied your request. The Plan says the radiofrequency ablation
is 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 the neurolytic agent destruction
(64624). Our reviewer says that the requested items/services are not considered medically reasonable and
necessary in this case. Our physician reviewer found that this is an experimental/ investigational procedure.
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 neurolytic agent destruction (64624) have not been met. Therefore, we
decided that the Plan does not have to pre-approve the neurolytic agent destruction (64624).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of stabilization device (22867 and 22868).
You asked the Plan to pre-approve the insertion of stabilization device (22867 and 22868). You say that the
member will significantly benefit from the insertion of stabilizing device. You say that the decision to allow
coverage should be reconsidered. The Plan denied your request. The Plan says this service is considered
experimental and 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 the insertion of stabilization device
(22867 and 22868). Our reviewer says that the requested items/services are not considered medically
reasonable and necessary in this case. Our physician reviewer found that interspinous process distraction
devices remain experimental. 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 insertion of stabilization device (22867 and 22868) have not been met.
Therefore, we decided that the Plan does not have to pre-approve the insertion of stabilization device (22867
and 22868).
Appeal type: DME/ Orthotics
Decision: Unfavorable

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

We decided that the Plan does not have to pre-approve the MyoPro device.
You asked the Plan to pre-approve the MyoPro device. You say that you would like reconsideration because the requested device is medically necessary. The Plan denied your request. The Plan says this device is not considered the standard of care.
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 MyoPro device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found current clinical guidelines designate robotic therapy to be of "uncertain utility compared with dose-matched conventional upper limb exercise therapies" with unproven benefit in the home environment. In addition, provided records document the enrollee has a left shoulder subluxation which may be a contraindication to the use of the device. 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 MyoPro device have not been met. Therefore, we decided that the Plan does not have to pre-approve the MyoPro device.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Computed Tomography (CT) scan of the abdomen.
You asked the Plan to pre-approve the CT scan of the abdomen. You say that you would like reconsideration
because the CT scan is the next appropriate step into determining how to diagnose and treat your condition.
The Plan denied your request. The Plan says no medical records have been submitted to verify if the CT scan is
medically necessary.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are
medically necessary.
We looked at your, the file, and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the CT scan of the abdomen have not been met. Specifically, the documentation submitted does not
include any clinical information to confirm if Medicare criteria for coverage have been met. Of note, the record
indicates that the Plan requested this clinical information from your physician on multiple occasions and no
response was received. Therefore, we decided that the Plan does not have to pre-approve the Computed
Tomography (CT) scan of the abdomen.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your
request. The Plan says step therapy guidelines were not followed.
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 drug. Our reviewer says that the
requested drug is not medically reasonable or necessary. Our physician reviewer found the case file does not
contain documentation of a trial and failure of Orthovisc, Synvisc, and Synvisc-One. The documentation does
not support that Orthovisc, Synvisc, and Synvisc-One 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 drug have not been met. Therefore, we decided that the Plan does not have
to pre-approve Euflexxa for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services provided to the enrollee on July 1, 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 code 63047 is considered inclusive to code 22633 and code 63048 is considered inclusive to code 22634.
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 the denied codes is: CPT 63047: Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; lumbar CPT 63048: Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; each additional vertebral segment, cervical, thoracic, or lumbar (List separately in addition to code for primary procedure) We asked our coder 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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer found CPT 63047 was performed at the same level, with a CPT 22633) arthrodesis. Per Medicare if these procedures are performed at the same level, then modifier -59 is not allowed. In terms of CPT 63048, this procedure was performed at the same level, with a CPT 22634) arthrodesis. Per Medicare if these procedures are performed at the same level, then modifier -59 is not allowed. We looked at this coder'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 pay for surgical services provided to the enrollee on July 1, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an auricular stimulator device (64555).
You asked the Plan to pre-approve the auricular stimulator device. You say that the device is medically
necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that Implantation of electrodes requires surgery and
usually necessitates an operating room. The rules also state that Acupuncture treatments and devices are non-
covered except for the treatment of Chronic Low Back Pain.
We looked at the file and Medicare rules. The device at issue does not meet Medicare definition of a covered
peripheral nerve stimulator device. This device is an electro-acupuncture device. There is no record of chronic
low back pain. The device at issue is non-covered. Based on this information, we decided that Medicare rules
for coverage of the auricular stimulator device have not been met. Therefore, we decided that the Plan does not
have to pre-approve an auricular stimulator device (64555).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve whirlpool bath equipment.

You asked the Plan to pre-approve whirlpool bath equipment. You say that this equipment is medically necessary. The Plan denied your request. The Plan says this equipment does not serve a medical purpose.

The Plan must follow Medicare rules. Medicare rules say that whirlpool bath equipment is covered if the patient is homebound and has a (standard) condition for which the whirlpool bath can be expected to provide substantial therapeutic benefit justifying its cost. 

We looked at the file and Medicare rules. In this case, there is no evidence confirming whether you are homebound or not. Based on this information, we decided that Medicare rules for coverage of whirlpool bath equipment have not been met. Therefore, we decided that the Plan does not have to pre-approve whirlpool bath equipment.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6530.
You asked the Plan to pre-approve the compression stockings. You say that this is medically necessary. The
Plan denied your request. The Plan says there are no enhanced benefits for compression stockings.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are
noncovered because they do not meet the statutory definition of a surgical dressing.
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression
stockings identified with code A6530.
Appeal type: 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 enrollee does not meet criteria for IRF admission.
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
enrollee does not meet criteria for IRF admission. 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 respiratory failure and COVID
19 pneumonia. 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, in 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.
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 Dupixent 300mg.
You asked the Plan to pre-approve Dupixent. You say that Dupixent is medically necessary. The Plan denied
your request. The Plan says this drug is not eligible for coverage under the Part B medical benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Dupixent 300mg.
Benefits for Dupixent may be available under Medicare Part D. Contact the Plan that administers Part D
benefits for further information concerning any benefits and appeal rights.