Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Proton Beam Radiation Therapy (PBRT) services.  You asked the Plan to pre-approve PBRT services. You say that this procedure is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage 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 PBRT services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the patient agreed to consent to a registry study. This registry study enrolls any patient receiving proton therapy for any disease (which in my opinion should not be sufficient for claiming medical necessity, as any and all patients treated with radiation therapy could then be considered for proton therapy without consideration for true need of this service). Notably, registry studies are not clinical trials or studies, and have a much less rigorous development process.  A tumor registry does not address a specific scientific question but rather registers the patient's clinical and treatment information into a database for potential analysis in the future. It is not specified if a clinical trial review was sought other than this registry study. To date, there are no compelling data to suggest that proton therapy is superior to or more beneficial than intensity-modulated radiation therapy or image-guided radiation therapy. The generally accepted standard of care for prostate cancer is to only offer proton beam therapy on clinical trials, and to not routinely offer it to patients. As there is no evidence this is the type of clinical trial the enrollee is in, this service would not be considered medically reasonable and necessary.   We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of PBRT services have not been met. Therefore, we decided that the Plan does not have to pre-approve Proton Beam Radiation Therapy (PBRT) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a Nustep T5XRW recumbent cross trainer exercise machine.  You asked the Plan to pre-approve this item. You say that this is medically necessary. The Plan denied your request. The Plan says that the item at issue in this appeal does not serve a purpose that is primarily medical in nature.  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 Nustep T5XRW recumbent cross trainer exercise machine.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve home health aide services (CPT code G0156 x 41) and home health skilled nursing services (CPT code G0299 x 3), for the enrollee.  You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your request. The Plan says the services are not necessary.  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 the services. Our physician reviewer found home health aide services (CPT code G0156 x 41) and home health skilled nursing services (CPT code G0299 x 3), for the enrollee are not medically necessary. The records do not show that skilled nursing services are required to effectively provide treatment, care, and/or services in order to improve the enrollee's condition, or to establish/perform a maintenance program to maintain the enrollee's condition and/or prevent deterioration. The records do not show that skilled therapy services are required to effectively provide treatment, care, and/or services in order to improve the enrollee's level of function, or to establish/perform a maintenance program to maintain the enrollee's level of function and/or prevent deterioration. The enrollee has had ample time for instruction on medication and disease management. There are no complex wound care issues, new enteral feedings or intravenous (IV) medications. The enrollee has strong caregiver support and does not require home health aide services for forty-one (41) more visits. Furthermore, as the enrollee does not require ongoing skilled nursing or receiving skilled therapy the criteria of home health aide services per Section 50.2 is not met and the request for home health aide services is not reasonable and necessary to the treatment of the enrollee's illness or injury by the skilled professional staff.  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 home health aide services (CPT code G0156 x 41) and home health skilled nursing services (CPT code G0299 x 3), for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve knee arthroscopy with partial meniscectomy (29881) for the enrollee.  You asked the Plan to pre-approve these services. You say that the member has very good prognosis for being able to achieve maximum functionality capacity in performing daily activities. The Plan denied your request. The Plan says that the member does not have complaints of mechanical symptoms.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. The enrollee was being treated for complex tear of medial meniscus of the left knee. He presented with left knee persistent pain located along the medial aspect of his left knee. Exam reveals strength of five out of five. There is full range of motion. There is an antalgic gait. Moderate tenderness is noted over the left posterior medial and medial joint line. McMurray's is positive for moderate pain on the left and positive medially on the left. Magnetic resonance imaging (MRI) demonstrated medial meniscus posterior horn vertical longitudinal oblique tear extending to both the superior and inferiorly articular surface with propagation to the posterior root attachment and resultant mild extrusion of the meniscal body. He has tried and failed medications, home exercises, and cortisone injection. The x-ray dated August 31, 2021, demonstrated moderate narrowing of the medial joint spaces bilaterally. There is limited published, large-scale, long-term peer-reviewed literature that shows arthroscopic knee meniscectomy to be an effective and/or safe treatment when there is evidence of moderate arthritis in the knee. Major mechanical issues are not consistently evident. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these services.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve knee arthroscopy with partial meniscectomy (29881) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) provided on September 22, 2021.  You asked the Plan to pay for the problem focused limited oral evaluation. You say that the denial reason for this service is unacceptable. You also say that the Plan should not expect doctors to perform procedures without doing an evaluation. The Plan denied your request. The Plan says this service exceeds the frequency limitation in your benefit plan.  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.    Though the Plan offers a dental benefit in excess of Medicare coverage, problem focused limited oral evaluation (D0140) is limited to one procedure per plan year. The record shows that you received a problem focused limited oral evaluation (D0140) on August 4, 2021 and your problem focused limited oral evaluation (D0140) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) provided on September 22, 2021.
Appeal type: Practitioner Services
Decision: Partially Favorable

 We decided that the Plan has to provide reimbursement for the private duty nursing services up to the $5000 annual maximum. We decided that the Plan does not have to provide reimbursement for the private duty nursing services beyond the $5000 maximum.   You asked the Plan to provide reimbursement for the private duty nursing services up to the $5000 annual maximum. You say that this should be covered by the Plan. You state that the Plan changed the code submitted from S9124 (private duty nursing) to 99070 and is incorrectly denying on this basis. The Plan says that this was billed with noncovered code 99070. A corrected claim must be submitted to allow for payment.  We decided that the Plan has to provide reimbursement for the private duty nursing services up to the $5000 annual maximum.   Medicare rules do not allow for coverage of private duty nursing services. However, the Plan offers a supplemental benefit which provides up to $5000 per year toward private duty nursing services.  The Plan has indicated that this was billed incorrectly. However, the documentation clearly shows that the services are correctly reported as private duty nursing services, which are covered per the contract. The Plan did not provide any valid rationale to support noncoverage of these services. Therefore, we decided that the Plan has to provide reimbursement for the private duty nursing services up to the $5000 annual maximum.   We also decided that the Plan does not have to provide reimbursement for the private duty nursing services beyond the $5000 maximum.  As noted above, the Plan covers up to $5000 toward private duty nursing services as a supplemental benefit. As such, the Plan is not obligated to reimbursement more than this amount for the services. Therefore, we decided that the Plan does not have to provide reimbursement for the private duty nursing services beyond the $5000 maximum.  If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
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 intenslihera
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for laboratory services (81120, 81121, 81194, 81206, 81210, 81235, 81245, 81270, 81272, 81275, 81276, 81310, 81311, 81315, 81351) provided on April 29, 2021.
  
You asked the Plan to pay for laboratory services. You say that this was medically necessary. The Plan denied your request. The Plan says this was not billed correctly.
  
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS).
   
We looked at the file and Medicare rules. The testing at issue was billed with POS 81 for an independent laboratory, but the record shows that the sample was not taken in the laboratory. Based on this information, we decided that Medicare rules for coverage of laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services (81120, 81121, 81194, 81206, 81210, 81235, 81245, 81270, 81272, 81275, 81276, 81310, 81311, 81315, 81351) provided on April 29, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve continuation of SNF care from January 29, 2022, forward.  

You asked the Plan to pre-approve SNF care. You say that you are not ready for discharge, you cannot return home until you can walk and be mobile. You state you would be a huge fall risk at home. The Plan denied your request. The Plan says you no longer require daily skilled services and the continuation of SNF is not medically necessary.  

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 at the time of admission, you required skilled rehabilitation services to improve function due to weakness and deconditioning. There were no skilled nursing needs. As of January 28, 2022, you did not require any skilled nursing or rehabilitation services on a daily basis. You were not expected to make measurable gains within a reasonable and predictable period of time or require skilled therapy to prevent deterioration with mobility or activities of daily living (ADLs). You did not require skilled therapy to establish a safe and effective maintenance program. As a practical matter, you did not require any skilled services on an inpatient basis, at a SNF level of care as of January 28, 2022. You did not have any parental medications, complex wound care or nutrition given via a feeding tube. You received skilled care and improved; however, your functional improvement had plateaued by January 28, 2022, and you did not require any further inpatient skilled rehabilitation services. Your function was at or near your prior level of function and you could be discharged to a lower level of care for further services. As of January 28, 2022, you required custodial services. The denial for further inpatient skilled care is upheld.  

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 continuation of SNF care from January 29, 2022, forward.
Appeal type: Practitioner Services
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 treatment is safe, effective, and supported by its clinical benefits to patients. You say that the requested treatment is medically necessary. The Plan denied your request. The Plan says the use of the requested device is not supported for the use of this device for long term relief of back and leg pain. The Plan says that there are not clinical indications for this technology.  

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 a Vertiflex device is not considered medically reasonable and necessary in this case. Our physician reviewer found the Food and Drug Administration states that the Superion Interspinous Spacer is indicated to treat skeletally mature patients suffering from pain, numbness, and/or cramping in the legs (neurogenic intermittent claudication) secondary to a diagnosis of moderate lumbar spinal stenosis, with or without Grade 1 spondylolisthesis, confirmed by X-ray, magnetic resonance imaging and/or computed tomography evidence of thickened ligamentum flavum, narrowed lateral recess, and/or central canal narrowing. 

The Superion Interspinous Spacer is indicated for those patients with impaired physical function who experience relief in flexion from symptoms of leg/buttock/groin pain, with or without back pain, who have undergone at least 6 months of non-operative treatment. The Superion Interspinous Spacer may be implanted at one or two adjacent lumbar levels in patients in whom operative treatment is indicated at no more than two levels, from L1 to L5. The Food and Drug Administration states that the requested procedure is contraindicated if a decompression procedure at the index level has been performed. The enrollee has chronic low back pain and lumbar spinal stenosis with claudication. The record indicates that the enrollee has severe central spinal stenosis at L4-l5, the level requested for treatment. The record states that the enrollee is indicated for surgery due to the multi-level nature of his disease.  

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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a specialist telehealth visit provided on August 30, 2021.  

You asked the Plan to waive the copayment for the specialist telehealth visit. You say that according to your coverage, telehealth visits have a $0 copayment. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.  

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment for services obtained from a specialist, including telehealth visits.   

You have been asked to pay a $40 copayment for the specialist telehealth visit. Please note that the virtual visit $0 copayment only applies to primary care physician (PCP) visits and urgently needed services. The specialist telehealth visit falls within the Physician/Practitioner Services, Including Doctor's Office Visits benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a specialist telehealth visit provided on August 30, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the intracept procedure (CPT code(s): 22899, C9753, and C9752), for the enrollee.  You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your request. The Plan says unproven and not medically necessary procedures are not covered by Medicare due to insufficient evidence of efficacy.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve the intracept procedure (CPT code(s): 22899, C9753, and C9752), for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the MyoPro Motion G Orthotic device (CPT code L8702), for the enrollee.  You asked the Plan to pre-approve the device. You say that the device is necessary. The Plan denied your request. The Plan says the request is not medically necessary because this device has deluxe features that exceeds the enrollee's needs and replaces, rather than improves the function of the enrollee's arm.  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 device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation that the MyoPro Motion G Orthotic device at issue in this case meets Medicare criteria for medically reasonable and necessary. 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.  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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the MyoPro Motion G Orthotic device (CPT code L8702), for the enrollee.