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

We decided that the Plan does not have to pre-approve a cup holder bracket for your wheelchair and one (1) unit of labor time requested (each unit of labor is 15 minutes) to repair your wheelchair.
You asked the Plan to pre-approve the services. You say that you are in need of the bracket replaced on the chair because you live in the chair and need the cup holder that was damaged when the wheel fell off of the chair. The Plan denied your request. The Plan says the cup holder/bracket are not covered as they are considered personal convenience items and do not serve a medical purpose.
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 cup holder bracket for your wheelchair and one (1) unit of labor time requested (each unit of labor is 15 minutes) to repair your wheelchair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the CGM Device (freestyle).
You asked the Plan to pre-approve the CGM. You say that the device is necessary. The Plan denied your request. The Plan says the Medicare rules have not been met.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Review of the medical records does not show that you meet the criteria for a CGM. You did not meet the rule criteria listed above in the Medicare Rules section for numbers 2 through 6. Therefore, we decided that the Plan does not have to pre-approve the CGM Device (freestyle).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex Superion spacer.
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan
denied your request. The Plan says the services are 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 these services. Our reviewer says that
the services are not medically necessary. Our physician reviewer found the enrollee has chronic pain from
spinal stenosis. Current evidence based medical guideline and peer reviewed literature do not fully support the
spinal decompression device procedure over the 'gold standard' of lumbar laminectomy. There is a lack of
large volume, long-term peer-reviewed outcome studies to support the use of the Vertiflex Superion spacer for
this enrollee's medical condition. The services are experimental in nature and 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 these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve a Vertiflex Superion spacer.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the wrist brace (E1805) to be provided by an out of network provider.
You asked the Plan to pre-approve the wrist brace. You say that you prefer the out-of-network supplier to the plan's contracted provider. The Plan denied your request. The Plan says there are network providers able to supply this item.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items at issue in this appeal. We found no exception that would require the Plan to pre-approve these items. Therefore, we decided that the Plan does not have to pre-approve the wrist brace (E1805) to be provided by an out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the toilet rail (CPT Code E0243).
You asked the Plan to pre-approve the toilet rail. You say that the toilet rail is necessary. The Plan denied your request. The Plan says the toilet grab bar is not covered for any condition because 1. it is a self-help item and 2. it is not used for a medical reason.
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 the toilet rail (CPT Code E0243).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the sclerosant injection coded 36471 provided on June 15,
2020.
You asked the Plan to pay for the sclerosant injection. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.
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 36471 is injection of sclerosant; multiple incompetent
veins (other than telangiectasia), same leg.
We find that CPT code 36471 is not supported in the medical record. Specifically, the documentation does not
support that injection of sclerosant; multiple incompetent veins (other than telangiectasia),
same leg was performed. Based on this information, we decided that Medicare rules for coverage of the
sclerosant injection have not been met. Therefore, we decided that the Plan does not have to pay for the
sclerosant injection coded 36471 provided on June 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the core buildup, including any pins when required provided on June 17, 2020.
You asked the Plan to pay for the core buildup. You say that you received a filling only, not a core buildup. The Plan denied your request. The Plan says this service is not covered.
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 the core buildup, including any pins when required provided on June 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the routine vision check, and eye refraction provided on
October 4, 2019.
You asked the Plan to pay for the routine vision check and eye refraction. You say that you would like this
claim processed and approved for payment. The Plan denied your request. The Plan says these services are not
covered when not performed by the Plan's routine vision provider.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in
this case. The Plan covers these services when they are obtained through the Plan's routine vision vendor.
We looked at the file and the Plan's rules. Although the services were provided by a contracted provider with
the Plan, the services were not obtained through the specific routine vision vendor that the Plan requires
perform the services. Based on this information, we decided that the Plan's rules for coverage of the routine
vision check and eye refraction have not been met. Therefore, we decided that the Plan does not have to pay for
the routine vision check, and eye refraction provided on October 4, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve power seat elevation system, any type (CPT Code E2300).
You asked the Plan to pre-approve power seat elevation system. You say that you are asking for this feature to reach your cooktop. The Plan denied your request. The Plan says the Medicare rules have not been met.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of power seat elevation system have not been met. This item is denied because a power elevating seat would not allow you to perform independent activities of daily living. You currently do not work and a power elevating seat would not change your transfer ability. You perform a safe stand pivot transfer. Therefore, we decided that the Plan does not have to pre-approve power seat elevation system, any type (CPT Code E2300).
Appeal type: Surgery
Decision: Unfavorable

You asked the Plan to pre-approve a lumbar laminectomy. 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 a lumbar laminectomy. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee presents with a 3-month history of mild to moderate low back pain radiating into the lateral thighs to the bottom of the feet, left more than right, with left lower extremity weakness. Clinical exam findings have documented motor weakness consistent with imaging evidence of spinal stenosis at the L4/5 and L5/S1 levels. Current evidence-based medical literature would not support surgical intervention at this time. There is no evidence of a recent 3 to 6 months of reasonable and/or comprehensive non-operative treatment protocol trial and failure. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request prior to attempted conservative treatment. Therefore, this request for lumbar laminectomy is not 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 a lumbar laminectomy have not been met. Therefore, we decided that the Plan does not have to pre-approve a lumbar laminectomy.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genicular radiofrequency nerve ablation services.
You asked the Plan to pre-approve the requested services. You say that the enrollee reports significant, but
unsustained relief with a recent genicular nerve block injection. The Plan denied your request. The Plan says
the service is considered experimental for the enrollee's condition.
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 requested services. Our physician
reviewer found that the enrollee has a history of bilateral knee pain due to osteoarthritis. She has been treated
with medical therapy, aquatic therapy, and interventional pain procedures. The enrollee received a right and left
genicular nerve block, with a reported 80% pain relief. Genicular nerve blocks and genicular nerve ablation are
considered investigational and not medically necessary for the treatment of chronic knee pain. The requested
genicular radiofrequency nerve ablations are not safe and effective to treat the enrollee. The requested
treatment is not medically reasonable or necessary to treat the enrollee's 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 requested services have not been met. Therefore, we decided that the Plan
does not have to pre-approve genicular radiofrequency nerve ablation services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to a tertiary-level urologist.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the tertiary level of care 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 these services. Our reviewer says that the tertiary level of care is not medically necessary. Our physician reviewer found the submitted records show that you have recurrent urinary tract infections, urinary urgency, urge incontinence, stress incontinence, and pelvic pain. Care for these conditions does not require a tertiary provider. Your care can be provided by an in-network, primary urologist. Tertiary care is 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a referral to a tertiary-level urologist.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a telehealth specialist visit (99213) provided June 24, 2020.
You asked the Plan to waive the copayment for the telehealth specialist visit. You say that the copayment should be waived because the service was provided via telehealth. The Plan denied your request. The Plan says the correct copayment was applied.
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 Specialist visits. You have been asked to pay a $40 copayment for the telehealth specialist visit. The telehealth specialist visit falls within the Specialist 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 telehealth specialist visit (99213) provided June 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the contact lens (V2500) purchased on July 21, 2020, from an out-of-network (OON) provider.
You asked the Plan to waive the coinsurance for the contact lenses. You say that you were unaware you would be charged a coinsurance amount. The Plan denied your request. The Plan says the coinsurance processed correctly for this claim.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services at a 50% coinsurance rate when routine eye wear is purchased OON. We looked at the file and the Plan's rules. The file indicates that you purchased contact lenses from an OON provider and were charged a coinsurance of 50%. Based on this information, we decided that the Plan's rules for coverage of the contact lens have processed correctly according to your plan benefits.
Therefore, we decided that the Plan does not have to waive the coinsurance for the contact lens (V2500) purchased on July 21, 2020, from an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the enrollee has rehab needs to improve strength,
endurance, mobility, and activities of daily living. The Plan denied your request. The Plan says the enrollee is
hemodynamically stable with no acute ongoing medical needs.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described above.
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 physician reviewer found
that the enrollee was admitted to the acute care hospital for a stroke. His medical problems are stable. The
complexity of his nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay
with an interdisciplinary approach to rehabilitation care. The medical record supports a need for physical and
occupational therapy, but it does not support a need for an intensive rehabilitation therapy program.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips.
You asked the Plan to pre-approve additional routine transportation trips. You say that you are requesting additional routine transportation trips. The Plan denied your request. The Plan says you exhausted your benefit. Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 36 one-way trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. The 37th trip and beyond is not a covered benefit. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve intensity-modulated radiation therapy (IMRT) with
daily image guidance.
You asked the Plan to pre-approve IMRT. You say that you are appealing. The Plan denied your request. The
Plan says the denial of authorization for these services is correct, because there is no research showing that the
enrollee's cancer responds better to this type of treatment compared to 3-dimensional conformal radiation
therapy.
The Plan follows Medicare rules. Medicare rules say that IMRT may be covered when the clinical criteria
listed in the previous section have been met.
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 IMRT. Our reviewer says that the
enrollee does not meet the Medicare criteria for the requested radiation therapy. Our physician reviewer found
according to a study, for an enrollee with mediastinal nodal disease undergoing mediastinal radiation, IMRT
can be considered a standard of care approach. However, this enrollee has node negative disease, and therefore
study results do not apply as the lung exposure would be expected to be relatively low, particularly with an
apical lung lesion. Based on the provided computed tomography (CT) scan, the primary tumor seems to be
away from the spinal cord, esophagus, and brachial plexus, and is far removed from the heart. Without a
dosimetric comparison, the need for IMRT is not justified. Even in the absence of a dosimetric comparison,
there is no plausible rationale for the need for IMRT provided.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IMRT have not been met. Therefore, we decided that the Plan does not have to
pre-approve intensity-modulated radiation therapy (IMRT) with daily image guidance.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the facet joint injection billed for services provided on January 27, 2020.
You asked the Plan to pay for the service provided. The Plan denied your request. The Plan says the billed code is not supported.
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 64495 is injection(s), diagnostic or therapeutic agent, paravertebral facet joint with image guidance, lumbar or sacral; third and any additional level(s) (List separately in addition to code for primary procedure). We find that CPT code 64495 is not supported in the medical record. The records provided do not indicate that a third level was performed on the date of service at issue. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the facet joint injection billed for services provided on January 27, 2020.