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

We decided that the Plan does not have to pre-approve the below knee flex cover system, an axial rotation unit, and shank foot system with vertical loading pylon.
You asked the Plan to pre-approve the below knee flex cover system, an axial rotation unit, and shank foot system with vertical loading pylon. You say that you would like reconsideration because the requested equipment is medically necessary. The Plan denied your request. The Plan says the requested equipment 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 the below knee flex cover system, an axial rotation unit, and shank foot system with vertical loading pylon. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer
found the documentation does not reveal that the member has a medical need for the extra protective cover or will be exposed to harsh or wet environmental conditions. The documentation does not reveal that the member requires a dynamic response pylon as the member does not have a hip disarticulation. The physician medical progress note documentation does not reveal or support that the member is a K3 ambulator therefore the advanced foot is also not medically 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 the below knee flex cover system, an axial rotation unit, and shank foot system with vertical loading pylon have not been met. Therefore, we decided that the Plan does not have to pre-approve the below knee flex cover system, an axial rotation unit, and shank foot system with vertical loading pylon.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion (99601) provided on January 1, 2021, through January 26, 2021.
You asked the Plan to pay for the home infusion. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says CPT code 99601 has a status indicator of I and is not valid for Medicare purposes.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code 99601 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT code 99601 has a status indicator of I. This means that CPT code 99601 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the home infusion have not been met.
Therefore, we decided that the Plan does not have to pay for the home infusion (99601) provided on January 1, 2021, through January 26, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Neulasta.
You asked the Plan to pre-approve Neulasta. The Plan denied your request. The Plan says the chemotherapy prescribed does not have a high risk of decreasing the enrollee's ability to fight an infection.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise 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 Neulasta. Our reviewer says that Neulasta as a primary prophylaxis is not medically necessary. Our physician reviewer found the enrollee's chemotherapy consists of Carboplatin and Alimta. Our reviewer also found that there is a less than 10% risk of Febrile Neutropenia with this chemotherapy regimen. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Neulasta have not been met. Therefore, we decided that the Plan does not have to pre-approve Neulasta.
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 IRF 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 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 documentation does not support the need for therapy program consisting of at least 3 hours of therapy per day at least 5 days per week with frequent physician oversight and an interdisciplinary approach to rehabilitation 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.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to provide Avsola (Q5121x20) without methotrexate.
You asked the Plan to provide Avsola (Q5121x20) without methotrexate. You say that you want to treat the enrollee with this drug. The Plan denied your request. The Plan says the drug is indicated for rheumatoid arthritis in combination with methotrexate and off label use would not be any different than use of Remicade without methotrexate which the enrollee tried and failed.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to provide Avsola (Q5121x20) without methotrexate. Our reviewer says that the requested use of Avsola without methotrexate is not Food and Drug Administration-approved for treatment of rheumatoid arthritis. Our physician reviewer found the requested use of Avsola without methotrexate for treatment of rheumatoid arthritis is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. The requested use of Avsola without methotrexate is not indicated, supported or recommended in any of the compendia for treatment of rheumatoid arthritis.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Avsola (Q5121x20) without methotrexate have not been met. Therefore, we decided that the Plan does not have to provide Avsola (Q5121x20) without methotrexate.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex Superion interspinous device.
You asked the Plan to pre-approve a Vertiflex Superion interspinous device. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.
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 a Vertiflex Superion interspinous device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the provided records do not document that the enrollee s not indicated for operative treatment at more than two levels. 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 a Vertiflex Superion interspinous device have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex Superion interspinous device
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 14 home health skilled nursing visits.
You asked the Plan to pre-approve 14 home health skilled nursing visits. 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 home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.
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 14 home health skilled nursing visits. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee does not have documented skilled nursing needs. The enrollee's needs appear to be custodial. As such, the requested, ongoing, home health skilled nursing services are not medically necessary or reasonable. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 14 home health skilled nursing visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 14 home health skilled nursing visits.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient hospital admission for a planned total hip replacement.
You asked the Plan to pre-approve the inpatient admission. You say that the enrollee should be allowed to be an inpatient for this procedure. The Plan denied your request. The Plan says this procedure is appropriate for completion in the outpatient setting. If there are complications, inpatient admission can be approved at that time.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 inpatient admission. Our reviewer
says that the documentation does not support that the criteria for inpatient coverage are met in this case. Our physician reviewer found the enrollee's medical history is significant for hypercholesterolemia, hypertension, type 2 diabetes, and renal failure status post kidney transplant on immunosuppression. Based on the provided documentation, the patient is stable and would not be expected to require inpatient hospital services that would likely cross 2 midnights for this lower risk procedure. Although his medical history may lead to complication, conversion to inpatient status can be considered if this occurs. 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 inpatient admission have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient hospital admission for a planned total hip replacement.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (76641) provided on March 24, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is 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 76641 is "Ultrasound, breast, unilateral, real time with image documentation, including axilla when performed; complete". 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 use of code 76641 is not supported by the records provided. Our reviewer found that the provided radiography report is insufficient
to show that a complete ultrasound was performed. As such, the billing of CPT 76641 is not supported. 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 the services (76641) provided on March 24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an advanced foot for your approved leg prostheses.
You asked the Plan to pre-approve an advanced foot for your approved leg prostheses. You say that the requested advanced foot is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested advanced foot.
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 an advanced foot for your approved leg prostheses. Our reviewer says that the enrollee does not meet criteria for the requested advanced foot. Our physician reviewer found the review indicates that the enrollee is a bilateral amputee (left above knee amputation on 10/30/2020 and right below knee amputation on 5/9/2021). Service requests are for preparatory right leg below the knee and preparatory Left leg above the knee. He does not have any prosthesis at this time. Member is appealing right transtibial prosthesis. Request for a K3 components exceeds the member's need and does not meet the Medicare criteria of reasonable and necessary. 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 an advanced foot for your approved leg prostheses have not been met. Therefore, we decided that the Plan does not have to pre-approve an advanced foot for your approved leg prostheses.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an additional mileage allowance for transportation services (A0170).
You asked the Plan to pre-approve an additional mileage allowance for transportation services. You say that you need to get to this provider location for surgery. The Plan denied your request. The Plan says your benefit only allows 36 one-way trips with each one-way trip not exceeding 50 miles of driving distance.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers routine transportation when the driving distance for a one-way trip is within 50 miles.
We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met. Specifically, the provider is located 90.5 miles away from your residence. The Plan only covers distances up to 50 miles. Therefore, we decided that the Plan does not have to pre-approve an additional mileage allowance for transportation services (A0170).
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 documentation does not support the need for an admission to an SNF. The enrollee's rehabilitation needs can be met at a lower intensity level with intermittent therapies as needed. 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.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve breast augmentation with implant and mastopexy.
You asked the Plan to pre-approve breast augmentation with implant (19325) and mastopexy (19316). You say that because of a surgery your breasts are sagging, and you need implants. The Plan denied your request. The Plan says the procedures appear to be for cosmetic reasons.
The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are coverable. 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 breast augmentation with implant (19325) and mastopexy (19316). Our reviewer says that the service is not medically necessary. Our reviewer found the documentation is insufficient to demonstrate that the requested breast augmentation with implant and mastopexy is medically reasonable and necessary for the enrollee in this case. There is insufficient documentation of trial and failure of antifungal and/or corticosteroid agents for the treatment of intertrigo. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of breast augmentation with implant (19325) and mastopexy (19316) have not
been met. Therefore, we decided that the Plan does not have to pre-approve breast augmentation with implant and mastopexy.
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 requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a 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 admission to a LTACH is not medically necessary. Our physician reviewer found the enrollee was admitted for shortness of breath and found to have a septic knee. The enrollee acute on chronic hypoxemic hypercapnic respiratory failure. The enrollee is improving. 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. The elements of the coverage rules 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 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 3 power wheelchair (PWC) with multiple
power options and all related accessories and components.
You asked the Plan to pre-approve the Group 3 PWC. You say that the enrollee requires this PWC. The Plan
denied your request. The Plan says the request was made for a Group 3 PWC, and the enrollee does not have
the required diagnosis for this item. A request for a Group 2 PWC would be considered if an authorization
request was made for this code.
The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for
enrollees who have a mobility limitation that is due to a neurological condition, myopathy, or a congenital
skeletal deformity.
The file does not show that the enrollee has a mobility limitation that is due to a neurological condition,
myopathy or congenital skeletal deformity. Therefore, we decided that the Plan does not have to pre-approve a
Group 3 power wheelchair (PWC) with multiple power options and all related accessories and components.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a total hip arthroplasty.
You asked the Plan to pre-approve a total hip arthroplasty. You say that the requested total hip arthroplasty is medically necessary. The Plan denied your request. The Plan says the requested total hip arthroplasty 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 a total hip arthroplasty. Our reviewer says that the requested total hip arthroplasty is not medically necessary. Our physician reviewer found the record indicates that the enrollee has primary osteoarthritis of the hip and has used Tylenol and had one steroid injection that provided three weeks relief. The record does not indicate a trial of physical therapy or NSAID use. The provided record indicates that the enrollee mainly has pain when walking. The primary record does not indicate that physical therapy has been tried and failed or that there is a contraindication to physical therapy. The provided records do not support the medical necessity and reasonableness, as defined by Medicare rules, of the requested service for the enrollee's condition. 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 a total hip arthroplasty have not been met. Therefore, we decided that the Plan does not have to pre-approve a total hip arthroplasty.