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

We decided that the Plan does not have to pre-approve an oxygen concentrator.

You asked the Plan to pre-approve the concentrator. You say that this is medically necessary. The Plan denied your request. The Plan says there is no documentation of an associated awake arterial blood gas or oximetry test documenting either hypoxemia or hypoxia.

The Plan must follow Medicare rules. The rules say that to qualify for portable oxygen, the patient must meet the criteria for home oxygen. The documentation must show that the patient is mobile in the home and would benefit from the use of portable oxygen in the home. Portable oxygen is not covered for patients who qualify for oxygen solely based on blood gas studies obtained during sleep.

To qualify for home oxygen, the patient must meet one of the following blood gas levels: 

1. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, at rest; 

2. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, taken during sleep for a patient who have hypoxia symptoms during sleep; 

3. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88%, taken during exercise for patients who have hypoxia symptoms during exercise; 

4. Arterial PO2 between 56 and 59 mmHg and arterial O2 saturation is 89% on room air if there is evidence of dependent edema, pulmonary hypertension, or erythrocythemia. 

For patients with arterial PO2 at or above 60 mm Hg or arterial O2 saturation at or above 90% on room air, there is a rebuttable presumption of non-coverage.

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 concentrator. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found home supplemental oxygen is considered not medically necessary. The records do not include oxygen saturations or ABGs that meet criteria for oxygen need, either within 2 days of discharge or as an outpatient in a stable state. Thus, the need for oxygen 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 concentrator have not been met. Therefore, we decided that the Plan does not have to pre-approve an oxygen concentrator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve medical necessity bag hooks (K0108).

You asked the Plan to pre-approve bag hooks. You say that the enrollee cannot propel a manual wheelchair due
to the diagnosis and her previous wheelchair is currently in need of a significant number of repairs. The Plan
denied your request. The Plan says this item 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.

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 medical necessity bag hooks (K0108).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a cast post and filling for a crown (D2952), and a
porcelain fused to high noble metal crown (D2750) for tooth # 11.

You asked the Plan to pre-approve the dental services. You say that these services should be covered. The Plan
denied your request. The Plan says 1 crown per tooth is covered every 5 years. The Plan also says that the
frequency limits have 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 the services are covered, the
frequency limits have been reached. The record shows that the Plan paid for a cast post and filling for a crown
for tooth # 11 that you received on July 30, 2019. The record shows that the Plan paid for a porcelain fused to
high noble metal crown for tooth # 11 that you received on February 28, 2020. Therefore, we decided that the
Plan does not have to pre-approve a cast post and filling for a crown (D2952), and a porcelain fused to high
noble metal crown (D2750) for tooth # 11.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics (L3020).

You asked the Plan to pre-approve foot orthotics. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says these items are not a covered benefit under the enrollee's contractual policy or by Medicare for her condition.

Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. 

Records show that the enrollee does not suffer from diabetic foot disease and does not wear a shoe that is an integral part of a leg brace. Inserts and other shoe modifications are covered if they are on a shoe that is an integral part of a covered brace and if they are medically necessary for the proper functioning of the brace. Although orthotics may be appropriate for her, neither Medicare nor the Plan provides coverage of orthotics for her condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics (L3020).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the skin substitute application procedures provided on January 28, 2021, billed with codes 15271 and 15275.
You asked the Plan to pay for the skin substitute applications as billed. You say that the services were correctly billed and should be paid. The Plan denied your request. The Plan says these codes are not supported by the medical records.
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 15271 is application of skin substitute graft to trunk, arms, legs, total wound surface area up to 100 sq cm; first 25 sq cm or less wound surface area.
The manual definition of 15275 is application of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area up to 100 sq cm; first 25 sq cm or less wound surface area. We asked our coding 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 the skin substitute applications as billed. Our reviewer says that the medical records do not support the services as billed in this case. Our coding reviewer found the medical records submitted does not include sufficient documentation to validate the billing of the skin substitute as there is no documentation of the fixation technique. Therefore, the performance of these services cannot be verified. 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 skin substitute applications as billed have not been met. Therefore, we decided that the Plan does not have to pay for the skin substitute application procedures provided on January 28, 2021, billed with codes 15271 and 15275.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional physical therapy services.

You asked the Plan to pre-approve additional visits. You say that the enrollee demonstrates improvable deficits. The Plan denied your request. The Plan says the enrollee does not need the ongoing skills of a physical therapist.

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.

The file shows that 10 physical therapy visits were requested. The plan pre-approved 2 visits. 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 additional visits. Our physician reviewer found that the enrollee has had prior extensive outpatient therapy visits. The records do not demonstrate that the ongoing unique skills of a professional therapist are required to provide treatment beyond what was approved by the plan.

The enrollee has been authorized additional therapy to ensure competence in a home exercise program. The requested services are not part of a maintenance program. The specialized skill of a qualified therapist are not required to establish, design or deliver a program to maintain her current condition or to prevent or slow further deterioration.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of additional visits have not been met. Therefore, we decided that the Plan does not have to pre-approve additional physical therapy services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an unspecified preventive procedure (D1999) provided on October 26, 2020.
You asked the Plan to pay for an unspecified preventive procedure. You say that you want the Plan to pay for the service. The Plan denied your request. The Plan says the service at issue is not a covered benefit.
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, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for an unspecified preventive procedure (D1999) provided on October 26, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve removal of impacted tooth (D7240), and therapeutic parenteral drugs (D9612).
You asked the Plan to pre-approve removal of impacted tooth, and therapeutic parenteral drugs. You say that you want the Plan to pay for these services. The Plan denied your request. The Plan says the services at issue are not covered benefits.
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, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve removal of impacted tooth (D7240), and therapeutic parenteral drugs (D9612).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a partial upper denture (D5213).
You asked the Plan to pre-approve the dental item. You say that the previous upper denture that you received
was never properly fitted. You also say that you need a set of dentures that you can actually use. The Plan
denied your request. The Plan says dentures are covered once every 5 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 listed as covered, the
frequency limit has been reached. The record shows that the Plan paid for a partial upper denture that you
received on May 11, 2018. Therefore, we decided that the Plan does not have to pre-approve a partial upper
denture (D5213).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a total electric hospital bed.
You asked the Plan to pre-approve the total electric hospital bed. You say that you have health issues and a total electric hospital bed would help you. The Plan denied your request. The Plan says a total electric hospital bed is non covered item.
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered. While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital bed.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve forehead reduction surgery with contouring for the
enrollee.

You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your
request. The Plan says cosmetic surgery or expenses incurred in connection with such surgery is not covered.

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 surgery. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found that in this case, the enrollee has gender dysphoria and forehead reduction surgery with contouring, or
facial feminization, is requested. The billing rules exclude this from coverage as a cosmetic service. The
elements of the coverage criteria are not satisfied.

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 surgery have not been met. Therefore, we decided that the Plan does not
have to pre-approve forehead reduction surgery with contouring for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Jazzy Passport power wheelchair.
You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied
your request. The Plan says this is not medically necessary.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not
have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.
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 wheelchair. Our reviewer says that
the requested wheelchair is not medically reasonable or necessary. Our physician reviewer found it is not clear
what specific activities of daily living are affected by your mobility deficit. The documentation does not reveal
that you have failed a lightweight manual wheelchair. There is no objective home evaluation indicating that
you can safely maneuver the requested device in the home. Furthermore, the documentation states that you
have an accessible kitchen, living room, and bedroom, but there are no objective measurements of doorways.
There is no mention of the bathroom being accessible. It is not clear that you are able to safely operate this
wheelchair. The documentation does not support that the requested wheelchair will significantly improve
MRADLs in the home.
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 wheelchair have not been met. Therefore, we decided that the Plan does not
have to pre-approve the Jazzy Passport power wheelchair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional accessories (E2300, K0108) for a power
wheelchair.

You asked the Plan to pre-approve the additional accessories. You say that these are needed for everyday
activities. The Plan denied your request. The Plan says these items are not covered because they are not
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 additional accessories (E2300, K0108) for a power
wheelchair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a heavy-duty rollator walker to be provided by an OON
provider.

You asked the Plan to pre-approve walker. You say that the facility near you does not have a stock for you to
look at and you do not know what models they have. The Plan denied your request. The Plan says the denial of
authorization for this item is correct, because this provider is out-of-network with the Plan and this item can be
received from an in-network durable medical equipment supplier.

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/services at issue in this appeal. We found no exception that would require
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve
a heavy-duty rollator walker to be provided by an OON provider.
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 this is medically necessary. The Plan denied your
request. The Plan says care can be safely given in a lower level of care.

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 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
has a past medical history of stroke in March 2021, was admitted for COVID-19 infection, then discharged to
live with daughter. 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 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 power seat elevation feature (E2300) and push handles for the enrollee.

You asked the Plan to pre-approve a power seat elevation feature and push handles. You say that these services are medically necessary. The Plan denied your request. The Plan says these items are not covered.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. Medicare rules also say that a power seat elevation feature is non-covered because it is not primarily medical in nature.

The push handles and power seat elevation feature do not serve a purpose that is primarily medical in nature. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation feature (E2300) and push handles for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).

You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says care could be received in another setting.

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 complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for surgical treatment of a femur fracture after a fall. 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.

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 admission to an inpatient rehabilitation facility (IRF).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a walk-in shower.

You asked the Plan to pre-approve the item. You say that this is medically necessary. The Plan denied your request. The Plan says this is considered primarily hygienic 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 walk-in shower.