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

We decided that the Plan does not have to pre-approve spinal magnetic resonance imaging.
You asked the Plan to pre-approve spinal MRIs. You say that you are in pain every day and need the MRIs because it burns. The Plan denied your request. The Plan says the supporting documentation did not show that the enrollee has tried and/or failed six weeks of conservative therapy.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve spinal MRIs. Our reviewer says that the MRIs are not medically necessary. Our physician reviewer found the review has determined that there is no specific clinical rationale for the requested imaging study. There are no reported physical exam abnormalities. The supporting documentation did not show that the enrollee has tried and/or failed six weeks of conservative therapy, including medication and physical therapy. The requested MRIs are 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 spinal MRIs have not been met. Therefore, we decided that the Plan does not have to pre-approve spinal magnetic resonance imaging.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor.

You asked the Plan to pre-approve the continuous glucose monitor. You say that the continuous glucose monitor is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.

The Plan must follow Medicare rules. Medicare rules say that 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 use daily insulin injections. Based on this information, we decided that Medicare rules for coverage of the continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 4Kscore testing (81539).

You asked the Plan to pre-approve 4Kscore testing. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says 4Kscore testing is not covered by Medicare or the Plan.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We looked at the file and Medicare rules. Medicare says that due to significant issues with assay validation and absence of clinical utility, 4Kscore testing is not reasonable and necessary and is not covered by Medicare. Therefore, we decided that the Plan does not have to pre-approve 4Kscore testing (81539).
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 stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.

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 was admitted for surgical treatment of a hip fracture after a fall. 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 IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve drugs or medicaments (D9630) and an application of desensitizing resin for cervical and/or root surface, per tooth (D9911 x 4).

You asked the Plan to pre-approve the dental services. You say that these services are medically necessary. You say that these services will prevent gum disease and help to ease the pain of having your wisdom teeth removed. The Plan denied your request. The Plan says drugs or medicaments is not listed as a covered service. The Plan says that application of desensitizing resin for cervical and/or root surface, per tooth, is not listed as a covered service either.

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 drugs or medicaments (D9630) and an application of desensitizing resin for cervical and/or root surface, per tooth (D9911 x 4).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a wedge pillow (E0190).

You asked the Plan to pre-approve a wedge pillow. You say that a regular pillow is not as effective for your condition as a wedge pillow. The Plan denied your request. The Plan says this item does not meet the definition of durable medial equipment and is not covered.

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 wedge pillow (E0190).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group two power wheelchair.

You asked the Plan to pre-approve a group two power wheelchair. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested device.

The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. 

The file shows that the enrollee has a power mobility device. The enrollee's current power mobility device serves the same purpose as a group two power wheelchair. The documentation does not support the condition of the enrollee's current power mobility device. The documentation does not include a face-to-face examination or video reference to a face-to-face examination. In addition, there is no home evaluation other than a note stating that the enrollee was performing some type of "home remodeling". Therefore, we decided that the Plan does not have to pre-approve a group two power wheelchair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve retreatment of previous root canal therapy (D3348).

You asked the Plan to pre-approve the dental service. You say that you need the retreatment of previous root canal therapy in order for you to receive the other service that the Plan already pre-approved. The Plan denied your request. The Plan says this service is not covered by Medicare or by the Plan's supplemental dental 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 pre-approve retreatment of previous root canal therapy (D3348).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Radiation Therapy for Liver Cancer (CPT code 77778), 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 guidelines do not support the routine use of the requested type of treatment (therapy) for the enrollee's cancer type. The Plan states it has not been shown that the enrollee's cancer type has responded well to the requested type of treatment.

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 Y-90 microspheres/radioembolization is medically necessary for non-colorectal cancer liver metastases when no other acceptable standard therapy is available, or no other therapy is likely to be effective (i.e. chemo-resistant tumors). There is a paucity of literature supporting Y-90 microspheres in patients with liver metastases from pancreatic adenocarcinoma, nevertheless, Y-90 microspheres can be considered medically necessary when other options are not available or are limited. This case is not clear why radioembolization is being offered in lieu of standard systemic chemotherapy. There is no indication that chemotherapy was offered to this enrollee or that chemotherapy would not be effective. The medical studies, for the most part, describe outcomes in patients with chemorefractory disease. Radioembolization would not be within accepted standards of care for a patient for whom chemotherapy is a viable option. 

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 Radiation Therapy for Liver Cancer (CPT code 77778), for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide power wheelchair accessories.

You asked the Plan to provide power wheelchair expandable controller, joystick receiver, mounting bracket, serviceable assembly, figure eight bracket slides, egg switch switches and egg switch extension cable, separately. You say that you need the power wheelchair accessories. The Plan denied your request. The Plan says the requested items cannot be requested separately.

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, we have confirmed that joystick receiver, mounting bracket, serviceable assembly, figure eight bracket slides, egg switch switches and egg switch extension cable have a bundled relationship with the approved accessories and cannot be requested separately. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to provide the remaining power wheelchair accessories.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Surgery to Place a Vertiflex Superion Device (CPT code 22869), 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 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 services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device remains experimental at this time. More research is needed to show safety and efficacy of Vertiflex. Open laminectomy is the gold standard for spinal stenosis decompression. 

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 Surgery to Place a Vertiflex Superion Device (CPT code 22869), for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve isosorbide mononitrate.

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 self-administered drugs are not covered.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve isosorbide mononitrate.

Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.

You asked the Plan to pre-approve foot orthotics. You say that the enrollee has chronic foot pain. The Plan denied your request. The Plan says this item is not a covered benefit.

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 you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home blood pressure monitor (A4670).

You asked the Plan to pre-approve the home blood pressure monitor. You say that the home blood pressure monitor is medically necessary. The Plan denied your request. The Plan says the home blood pressure monitor is not covered.

The Plan must follow Medicare rules. The rules say that Medicare covers home blood pressure monitors only for enrollees who are on home dialysis, or those who meet the criteria for white coat hypertension and require ABPM to confirm a diagnosis of hypertension.

The records do not show that this monitor is requested in the setting of home dialysis services, or that this request is for evaluation of suspected white coat hypertension. Although monitoring blood pressure in the home may be appropriate in this case, neither Medicare nor the Plan provides coverage of this item in this situation. Please note the plan documentation shows this item may be eligible for coverage under the plan's Over-the-counter benefit. Please contact the plan for details. Therefore, we decided that the Plan does not have to pre-approve a home blood pressure monitor (A4670).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an occlusal guard (D9940).

You asked the Plan to pre-approve the occlusal guard. You say that you would like this service to be covered. The Plan denied your request. The Plan says this service 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 pre-approve an occlusal guard (D9940).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable controller (E2377) and harness (E2313) for a Group 3 power wheelchair.

You asked the Plan to pre-approve an expandable controller and harness. You say that the requested items are medically justified. The Plan denied your request. The Plan says rules for approval have not been met because the requested items are not medically necessary.

The Plan follows Medicare rules. Medicare rules say that an expandable controller is used for one or more of the additional functions listed in the "Medicare rules" section of this letter. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve an expandable controller and harness. Our reviewer says that the requested items are not medically necessary. Our physician reviewer found that the documentation does not reveal that you require 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.). You 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. Your strength and function in the upper extremities indicates that you would have the ability to control any power options through their own individual switches. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an expandable controller and harness have not been met. Therefore, we decided that the Plan does not have to pre-approve an expandable controller (E2377) and harness (E2313) for a Group 3 power wheelchair.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested admission is not medically necessary.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee was admitted to the current acute care hospital with pneumonia complicated with acute respiratory failure requiring high flow oxygen and Bilevel Positive Airway Pressure. The documentation does not support that the enrollee requires services at the LTACH that are not available at the acute care hospital where the enrollee is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. Therefore, the enrollee does not meet criteria for the requested admission.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.