Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee does not need intensive therapies, consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach to daily therapy. While the enrollee may benefit from physical therapy, and occupational therapy, the enrollee's rehab needs can be safely met in an alternate and lower intensity setting such as in a skilled nursing 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 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.
You asked the Plan to pre-approve a shower chair. You say that the member needs this item. The Plan denied your request. The Plan says this is not a covered item.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve blood work to be provided every three months.
You asked the Plan to pre-approve blood work. You say that your physician advised to get blood work completed every three months. The Plan denied your request. The Plan says the requested services are not a covered benefit.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. Review of the file does not support that there is a physician order for the blood work every three months. This means the blood work at issue in this appeal is being requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pre-approve blood work to be provided every three months.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of stabilization device (22869 and 22870).
You asked the Plan to pre-approve the insertion of stabilization device (22869 and 22870). You say that the member has failed more than 10 years of conservative approaches to treatment. You say that this treatment is considered safe and effective, and the necessary coverage should be provided. 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 (22869 and 22870). Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case.
Our physician reviewer found that interspinous 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 (22869 and 22870) have not been met. Therefore, we decided that the Plan does not have to pre-approve the insertion of stabilization device (22869 and 22870).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says needs can be safely met with home health services at home with supervision or in an assisted living facility.
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 the admission. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found you do not qualify for SNF coverage. You do not have documented skilled nursing or skilled therapy needs. Daily skilled services are not shown to be required to establish a maintenance program or to prevent deterioration of your 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 the admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a cardiac ablation procedure (93655, 93650, 93656, 93622).
You asked the Plan to pre-approve the ablation procedure. You say that the procedure 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 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 ablation procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found at issue is the medical appropriateness and necessity of catheter ablation of atrial fibrillation. Insufficient clinical documentation was furnished to support the request. 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 ablation procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve a cardiac ablation procedure (93655, 93650, 93656, 93622).
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the 3D rendering with interpretation (76376) provided on May 24, 2021.  You asked the Plan to pay for the 3D rendering with interpretation. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says this service is considered integral to the radiology service.  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 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 3D rendering with interpretation. Our reviewer says that CPT code 76376 does not meet criteria for billing or reimbursement consideration. Our reviewer found 3D rendering with interpretation and reporting of computed tomography (CT), magnetic resonance imaging (MRI), ultrasound, or other tomographic modality with image post-processing under concurrent supervision; requiring image post-processing on an independent workstation may be considered medically unnecessary and denied if equivalent information obtained from the test has already been provided by another procedure (magnetic resonance imaging, ultrasound, angiography, etc.) or could be provided by a standard CT scan (two-dimensional) without reconstruction.  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 3D rendering with interpretation have not been met. Therefore, we decided that the Plan does not have to pay for the 3D rendering with interpretation (76376) provided on May 24, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI).
You asked the Plan to pre-approve an MRI. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.
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 an MRI. Our reviewer says that the documentation does not support that Our physician reviewer found the enrollee has a reported mass on left bicep. Examination findings included noting no discrete mass palpable, but a soft tissue lesion was palpated with the left biceps region slightly larger than the right. Arms nontender. Ultrasound of the are noted that the differential included muscle tear or hematoma, but no mass was clearly seen. Lipoma ruled out. X-ray is standard of care for initial evaluation of an upper extremity mass and should precede more advanced imaging. Therefore, as this enrollee has not yet completed an x-ray of the area, this request for MRI will be considered 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 an MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an epidural steroid injection.

You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the services are not medically necessary.

The Plan follows Medicare rules. Medicare rules say that epidural steroid injections are only covered under certain medical indications. 

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 requested services. Our physician reviewer found that the enrollee has chronic low back pain. She takes Gabapentin, Percocet, Morphine and Soma for pain. On imaging, she has spinal stenosis, multi-level disc degeneration and disc protrusions. She had an epidural steroid injection (ESI) on November 9, 2021, and received 85-90% pain relief. She has not had a surgical consult. The request is for a repeat ESI before 3 months. The request does not meet the criteria because it is made before 3 months. The request is therefore, deemed 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 the requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve an epidural steroid injection.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided on May 18, 2021, through May 19, 2021.
You asked the Plan to pay for acute inpatient hospital care. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation does not support the inpatient level of care.
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 pay for acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the member was admitted to the hospital with plans to repeat imaging. He remained hemodynamically stable and neurologically stable. Repeat imaging and basic monitoring could have been completed at a lower level of care and it was not expected that the patient would require hospital care that would likely cross 2 midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided on May 18, 2021, through May 19, 2021.
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 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the laparoscopic bariatric surgery.
You asked the Plan to pre-approve the laparoscopic bariatric surgery. You say that you would like
reconsideration because the requested surgery is medically necessary and the extra weight is causing you
medical discomfort. The Plan denied your request. The Plan says you do not meet Medicare criteria for
coverage because you have a BMI of 31.
The Plan must follow Medicare rules. The rules say that Medicare will cover bariatric surgery for enrollees
who have:
(1) a body mass index (BMI) of greater than or equal to 35;
(2) at least one co-morbidity related to obesity; and
(3) been unsuccessful with medical treatment for obesity.
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 laparoscopic bariatric surgery. Our
reviewer says that hte elements of the coverage criteria are not satisfied. Our physician reviewer found the
record indicates that you have a body mass index of less than 35.
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 laparoscopic bariatric surgery have not been met. Therefore, we decided that
the Plan does not have to pre-approve the laparoscopic bariatric surgery.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Enbrel SureClick injection.
You asked the Plan to pre-approve Enbrel SureClick. You say that the enrollee has been taking this medication
and it has been treating her disease effectively. 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 selfadministered
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 Enbrel SureClick injection.
Benefits for Enbrel SureClick 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 a Vertiflex device.
You asked the Plan to pre-approve a Vertiflex device. You say that the requested Vertiflex device is medically necessary. The Plan denied your request. The Plan says the requested Vertiflex device 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 Vertiflex device. Our reviewer says that the requested Vertiflex device is not medically necessary. Our physician reviewer found the Vertiflex device is experimental. More research is needed to show safety and efficacy. The requested Vertiflex device is not medically reasonable or necessary at this time. 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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a donut pillow.
You asked the Plan to pre-approve the pillow. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a donut pillow.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a BOA click system for socket (L5999).
You asked the Plan to pre-approve a BOA click socket. You say that you are not requesting an additional knee flexion feature, but the feature that comes with the knee, as indicted by code L5845. It is necessary for maximum safety during stance. The Plan denied your request. The Plan says this socket does not have FDA approval. It does not meet Medicare criteria as safe and effective. This item is experimental or investigational. A standard socket has been approved.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The rules also say that experimental and investigational devices are not covered. We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of BOA click socket have not been met. Therefore, we decided that the Plan does not have to pre-approve a BOA click system for socket (L5999).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the spine surgery (22899).
You asked the Plan to pre-approve the spine surgery (22899). You say that this procedure fills a treatment gap for patients that do not receive adequate relief from traditional conservative methods. You say that the evidence clearly supports the use of this procedure as primary treatment for chronic low back pain and the procedure should be authorized. The Plan denied your request. The Plan says there are not enough studies on Intracept to show it is safe and effective.
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 spine surgery (22899). Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that 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 spine surgery (22899) have not been met. Therefore, we decided that the Plan does not have to pre-approve the spine surgery (22899).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete denture - maxillary (D5110).
You asked the Plan to pre-approve a complete upper denture. You say that you are losing weight because your current dentures do not fit properly and are causing gum irritation. The Plan denied your request. The Plan says you have exceeded the frequency limit for this service.
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 complete upper denture once every five years. We looked at the file and Medicare rules. The Plan provided documentation showing that a complete upper denture was previously covered on September 8, 2020. Based on this information, we decided that the Plan's frequency limit for coverage of a complete upper denture has been exceeded. Therefore, we decided that the Plan does not have to pre-approve a complete denture - maxillary (D5110).