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

We decided that the Plan does not have to pre-approve a BMP-2 Allograft.
You asked the Plan to pre-approve a BMP-2 Allograft. You say that the requested service is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the requested service in question 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 a BMP-2 Allograft. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee is a 67-year-old female who is being treated for cervical disc disorder with radiculopathy; cervical spondylosis; neck pain; paresthesia of upper limb.
She presented with complaints of neck pain and bilateral arm pain. The enrollee was last seen on January 19, 2021, with similar complaints and has been working with pain management. She has neck pain localized to the posterior aspect of her cervical spine with bilateral radiation into her trapezius and shoulder regions. She also has complaints of pain and paresthesias that radiate along the posterior aspect of her bilateral upper extremities. Exam reveals decreased strength at 4+/5 in the bilateral deltoids. Sensation is diminished in the bilateral C7 distribution. There is mildly decreased bilateral rotation of the cervical spine. She was noted to have been approved for an anterior cervical discectomy and fusion. However, there is limited published, large-scale, long-term peer-reviewed literature that shows the requested Infuse BMP-2 Allograft to be an effective and/or safe treatment for the noted pathology. Detailed documentation is not evident as to why the "gold standard" treatment of autograft is not able to be utilized for this procedure. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the request for Infuse BMP-2 Allograft is not medically reasonable or 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 a BMP-2 Allograft have not been met. Therefore, we decided that the Plan does not have to pre-approve a BMP-2 Allograft.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve non-emergency wheelchair van transportation (A0130).  You asked the Plan to pre-approve non-emergency wheelchair van transportation. You say that you do not agree with the denial. You also say that the enrollee cannot drive, and she has no one to take her to her appointments. The Plan denied your request. The Plan says this service is not a covered benefit.  The Plan must follow Medicare rules. The rules say that Medicare does not pay for wheelchair van transport services.   The services you have asked the Plan to pre-approve are wheelchair van transport services. Specifically, this is not a covered benefit. Therefore, we decided that the Plan does not have to pre-approve non-emergency wheelchair van transportation (A0130) provided by Ethan T. Hoerschgen.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the transportation of portable x-ray equipment and personnel (R0070) provided on July 12, 2021.  You asked the Plan to pay for code R0070. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.  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 R0070 is Transportation of portable x-ray equipment and personnel to home or nursing home, per trip to facility or location, one patient seen.  We find that CPT code R0070 is not supported in the medical record. The provider reported transportation of portable radiology equipment but did not report setup codes, which does not follow industry standard coding rules. Transportation services are not reimbursable without the reporting of setup services. Diagnostic x-ray setup and transportation services were not performed by the portable x-ray provider. Therefore, we decided that the Plan does not have to pay for the transportation of portable x-ray equipment and personnel (R0070) provided on July 12, 2021.
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 the Intracept procedure. You say that this procedure is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the requested procedure 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 Intracept procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Intracept procedure is 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 Intracept procedure 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 acute inpatient rehabilitation facility (IRF) admission and services.  You asked the Plan to pre-approve IRF 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 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 in this case, the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute rehabilitation hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, at an intensive rehabilitation therapy 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the leg joint for the enrollee.

You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your request. The Plan says the notes from the doctor do not have enough information.

The Plan must follow Medicare rules. Medicare rules say that MRIs 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 the MRI. Our reviewer says that the requested MRI is not medically reasonable or necessary. Our physician reviewer found the enrollee has atraumatic left knee pain. There is prior history of arthroscopic repair of the knee. An MRI of the left knee has been requested; however, there is also a plan in place for physical therapy referral, which has not yet occurred. In additional, there are no physical exam findings which amount to red flags indicating immediate MRI without first trying conservative management. Also, there is no mention of recent plain x-rays of the knee. Absent such clinical data, the medical necessity of immediate MRI prior to completion of physical therapy is not established.

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 MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the leg joint for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an out-of-network referral for a power wheelchair and accessories.

You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says this is a network lock-in, and medically necessary care is available in network.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items at issue in this appeal.

We found no exception that would require the Plan to pre-approve these items. Therefore, we decided that the Plan does not have to pre-approve an out-of-network referral for a power wheelchair and accessories.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve facet joint injections.  You asked the Plan to pre-approve facet joint injections. You say that this is medically reasonable and necessary for the enrollee's condition. 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 there must be an absence of untreated radiculopathy or neurogenic claudication (except for radiculopathy caused by facet joint synovial cyst).  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 facet joint injections. Our reviewer says that the requested injection procedure.  Our physician reviewer found that the enrollee has low back pain with associated radiculopathy. The review has determined that the medical records provided do not meet the requirements listed in the LCD for Medicare coverage which document that there must be an absence of radiculopathy. The requested service is not medically reasonable or 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 facet joint injections have not been met. Therefore, we decided that the Plan does not have to pre-approve facet joint injections.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 25605 billed for date of service February 8, 2021.

You asked the Plan to pay for procedure code 25605. You say that this code should be paid. The Plan denied your request. The Plan says the medical records do not support payment of code 25605. There is a more appropriate code that should have been used. The medical records do not indicate that closed treatment of distal radial fracture with manipulation was performed.

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 25605 is closed treatment of distal radial fracture (eg, Colles or Smith type) or epiphyseal separation. 

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 procedure code 25605. Our reviewer says that procedure code 25605 is not supported in the medical record. Our reviewer found you reported code 25605 for services rendered. Documentation submitted was reviewed and does not meet criteria.

To cite the report "Splint was placed by RN, Neurovasculary intact both before and after splint placement". Documentation does not support manipulation of the affected area, and therefore cannot be confirmed as performed. 

We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of procedure code 25605 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 25605 billed for date of service February 8, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the genetic testing provided on September 14, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the genetic testing. You say that this genetic test is a Medicare-covered service and medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. The record shows the referring provider was out-of-network. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on September 14, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the tetanus immunization and administration (90698 and 90471) provided on July 1, 2021  You asked the Plan to pay for the tetanus immunization and administration. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says tetanus immunizations are not covered under your Medicare Part B benefit in this case.  In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the tetanus immunization and administration. The Plan follows the same rules.   Records do not show that you have been injured or directly exposed to any illness related to the tetanus immunization and administration. Therefore, we decided that the Plan does not have to pay for the tetanus immunization and administration (90698 and 90471) provided on July 1, 2021   Benefits for the tetanus immunization and administration 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve chiropractic services.

You asked the Plan to pre-approve chiropractic services. You say that you need minor adjustment because you are having pain around your peck muscles. The Plan denied your request. The Plan says the requested services are not medically necessary.

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. 

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 chiropractic services Our reviewer says that the documentation does not support that the requested chiropractic services are medically reasonable or necessary. Our physician reviewer found the record indicates that you have neck pain with radiculopathy. The examination does not demonstrate subluxation. Cervical X-rays reveal degenerative disc disease and normal alignment. Therefore, you do not meet criteria for the requested chiropractic 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 chiropractic services have not been met. Therefore, we decided that the Plan does not have to pre-approve chiropractic services.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Avsola (Q5121), 13 units.  You asked the Plan to pre-approve Avsola. You say that the requested drug is medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee has not tried and failed the required drugs, Remicade, Inflectra, or Simponi Aria.  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 Avsola. Our reviewer says that the requested drug, Avsola, is not medically necessary. Our physician reviewer found the provided documentation does not indicate that the enrollee has tried and failed the required drugs, Remicade, Inflectra, or Simponi Aria. The reviewer found that the documentation does not support that Remicade, Inflectra, or Simponi Aria (2 of 3) would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. Therefore, the reviewer found that the requested drug is not medically necessary as the step therapy criteria has not been 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 Avsola have not been met. Specifically, the file shows that the enrollee has not tried and failed the required drugs. Therefore, we decided that the Plan does not have to pre-approve Avsola (Q5121), 13 units.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Oxycodone/Acetaminophen tablet, 10-325 mg.

You asked the Plan to pre-approve Oxycodone/Acetaminophen. You say that the requested drug is medically necessary. The Plan denied your request. The Plan says the requested drug is considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the requested drug is not covered under Medicare Part B.

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 Oxycodone/Acetaminophen tablet, 10-325 mg.

Benefits for Oxycodone/Acetaminophen 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: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve repair/replacement of a heavy duty wheelchair.  You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says no documentation was provided from the physician with the request showing why repairs or a replacement of the wheelchair is needed.  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 services are not considered medically reasonable and necessary in this case. Our physician reviewer found the current wheelchair was approved on 2/28/20, and there is no detailed treating medical provider progress note information on why this approved wheelchair is unable to meet your needs. There is no information on why the wheelchair needs repair or a replacement.  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 repair/replacement of a heavy duty wheelchair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve lower limb prosthetic knee, shin, and foot components.  You asked the Plan to pre-approve lower limb prosthetic components. You say that these components are necessary for the enrollee to accomplish her vocational duties and anything lesser will greatly inhibit her. The Plan denied your request. The Plan says the denial of authorization for these components is correct, because the records are not consistent with the enrollee being a K3 ambulator and therefore these components exceed the enrollee's medical needs. The Plan also says that a request for K2 components could be reviewed instead.  The Plan must follow Medicare rules. Medicare rules state that determination of the medical need of lower limb prosthetic components is based on assessment of the enrollee's functional level. 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 lower limb prosthetic components. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation indicates that the enrollee's expected ambulatory aids even with the prosthesis include a cane and walker which is not consistent with K3 level ambulation. The requested components exceed the patient's medical and functional needs.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of lower limb prosthetic components have not been met. Therefore, we decided that the Plan does not have to pre-approve lower limb prosthetic knee, shin, and foot components.