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

We decided that the Plan does not have to pre-approve a sinus computed tomography (CT) scan.

You asked the Plan to pre-approve a CT scan. The Plan denied your request. The Plan says this is not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that CT scans 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 a CT scan. Our reviewer says that the requested CT scan is not medically reasonable and necessary in this case. Our physician reviewer found that the enrollee has a complaint of "sinus congestion". The clinical notes do not indicate if any pharmacological interventions, including over-the-counter medications have been tried as this may simply be allergic in nature. The requested sinus CT Scan 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 CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a sinus computed tomography (CT) scan.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says this 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 device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the device is experimental. More research is needed to show safety and efficacy of the Vertiflex device. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an adjustment to your hearing aid (A9270).

You asked the Plan to pre-approve an adjustment to your hearing aid. You say that you would like the Plan to pay for an adjustment of your hearing aid, rather than get a new one. The Plan denied your request. The Plan says hearing aid adjustments are not a covered service.

Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. 

We looked at the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of an adjustment to your hearing aid have not been met. Specifically, adjustment of hearing aids is not a covered benefit. Therefore, we decided that the Plan does not have to pre-approve an adjustment to your hearing aid (A9270).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 4Kscore testing for the enrollee.
You asked the Plan to pre-approve the testing. You say that this is medically necessary. The Plan denied your
request. The Plan says the PSA of 2 does not meet the criteria for his testing.
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 testing. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found the enrollee is a 75-year-old male with a long history of a PSA of 1 that has now increased to 2. He has
not had a prostate biopsy. With a PSA of 2, the criteria are not met per the LCD.
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 testing have not been met. Therefore, we decided that the Plan does not have
to pre-approve 4Kscore testing for the enrollee.
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 effectiveness of the requested
procedure has not been demonstrated in the peer-reviewed literature.

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 remains 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LipiFlow treatment (0207T).

You asked the Plan to pre-approve LipiFlow treatment. You say that you need this because your eye irritation
is affecting your daily life. The Plan denied your request. The Plan says this treatment has not been proven
beneficial.

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 LipiFlow treatment. Our reviewer says
that the requested services are not considered medically reasonable and necessary in this case. Our physician
reviewer found there is insufficient evidence to demonstrate that LipiFlow treatment is a safe and effective
treatment for the treatment of dry eye 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 LipiFlow treatment have not been met. Therefore, we decided that the Plan does
not have to pre-approve LipiFlow treatment (0207T).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.

You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your
request. The Plan says there is no evidence that this device is as safe and effective as the gold standard of
decompression.

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 services are not considered medically reasonable and necessary in this case. Our physician reviewer
found the device 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 device have not been met. Therefore, we decided that the Plan does not have
to pre-approve the Vertiflex device for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a prosthetic leg with a computerized knee and additional
components (L5856, L5848, L5828, L5845).

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your
request. The Plan says this request does not meet the Medicare criteria as reasonable and 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 services. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found the prosthetic leg with a computerized knee and additional components exceeds your medical needs
according to the guidelines. The documentation does not support that your functional needs would not be able
to be met with a mechanical K3 knee. Additionally, the documentation which indicate you have "pulled your
back out again," have a history of hospitalization for low back pain, cannot bend forward without significant
pain, and needs to continue Methocarbamol with one refill do not support that you are able to function at a K3
level.

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 a prosthetic leg with a computerized knee and additional components (L5856, L5848,
L5828, L5845).
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 these services are medically necessary. The Plan denied your request. The Plan says that your ongoing skilled therapy needs are being met in the current skilled nursing facility.

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. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for COPD exacerbation. Your medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your condition does not meet Medicare criteria for IRF 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: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for emergency room services (S5001) provided December 7, 2020 to December 10, 2020.

You asked the Plan to pay for the emergency room services. You say that the services were medically necessary. The Plan denied your request. The Plan says the billed CPT code is not eligible for Medicare payment.

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 S5001 is not supported in the medical record. Specifically, per the CMS National Physician Fee Schedule, code S5001 has a status indicator of "I" which indicates it is not valid for Medicare payment. Based on this information, we decided that Medicare rules for coverage of the emergency room services have not been met. Therefore, we decided that the Plan does not have to pay for emergency room services (S5001) provided December 7, 2020 to December 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable controller, expandable controller harness and electronic connection.
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that your upper extremity strength and function are adequate to control the power options using their own switch which are included in the allowance of these power options.
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. Records indicate you are independent with eating and have 3-5/5 right upper extremity strength and you have functional use of the right upper extremity to be able to control the power options with their own switches. Our physician reviewer found that your condition does not meet criteria for 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 an expandable controller, expandable controller harness and electronic connection.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a complete lower denture (D5120).

You asked the Plan to pre-approve the dental items. You say that you need these dentures for health reasons. You also say that you cannot wait 5 more years to chew your food. The Plan denied your request. The Plan says dentures are covered once every 5 calendar years. The Plan also says that the frequency limit has been reached.

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 and dentures are covered, the frequency limit has been reached. The record shows that the Plan paid for a complete upper denture and a complete lower denture that you received on February 4, 2019. Therefore, we decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a complete lower denture (D5120).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve auricular peripheral nerve stimulation for the enrollee.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the request does not meet CMS guidelines for this procedure.

The Plan must follow Medicare rules. Medicare rules say that acupuncture for stimulation of auricular points is not a covered Medicare benefit. 

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 Our physician reviewer found. 

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 auricular peripheral nerve stimulation for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2300, E2377, E2313, E2311) for the enrollee.

You asked the Plan to pre-approve the accessories. You say that this is medically necessary. The Plan denied your request. The Plan says this is not medically necessary.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.

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 accessories. Our reviewer says that the requested accessories are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee's strength and function in the upper extremities indicates that the patient can control any power options through their own individual switches. The enrollee does not need to operate 3 or more powered seating actuators through the drive control, a separate display (i.e., for alternate control devices), other electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive control), or an attendant control. The documentation does not reveal that the enrollee requires other types of proportional input devices (e.g., mini-proportional or compact joysticks, touchpads, chin control, head control, etc.) or non-proportional input devices (e.g., sip and puff, head array, etc.).

We looked at this physician's review, the file, and Medicare rules. Our doctor found that E2311, E2313, and E2377 are not medically reasonable or necessary. Additionally, E2300 is not considered primarily medical in nature based on Medicare guidelines. Based on this information, we decided that Medicare rules for coverage of the accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2300, E2377, E2313, E2311) for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that the member is currently unable to take care of herself
completely. You say that the member needs assistance to use the restroom and dressing. You say she is unable
to take care of daily needs in her current physical condition. The Plan denied your request. The Plan says that
based on Medicare guidelines, the IRF services you or your provider are requesting do not meet the
requirements for approval.

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 that the complexity of the enrollee's nursing, medical and rehabilitation needs does
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The
enrollee was admitted for stabilization of a cervical fracture after a ground level fall. The enrollee's medical
problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive
rehabilitation therapy program. While the medical record supports a need for physical and/or occupational
therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be
provided in a different level of care. There is not a reasonable expectation that this enrollee will be able to fully
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.

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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Intracept procedure.
You asked the Plan to pre-approve the Intracept procedure. The Plan denied your request. The Plan says this 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 Intracept procedure. Our reviewer says that the requested 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 of the procedure. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Intracept procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve an Intracept procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a wedge pillow and a cervical traction device.
You asked the Plan to pre-approve a wedge pillow and a cervical traction device. You say that you need these items. The Plan denied your request. The Plan says a wedge pillow is not a medical item and you do not meet criteria for a traction device.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The rules also say that cervical traction devices are covered only if the appropriate use of a home cervical traction device has been demonstrated to the beneficiary and the beneficiary tolerated the selected device. The wedge pillow 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. The requested cervical traction device cannot be covered because the records do not show that the appropriate use has been demonstrated to you and you have tolerated the device. Therefore, we decided that the Plan does not have to pre-approve a wedge pillow and a cervical traction device.