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

We decided that the Plan does not have to pre-approve a candy apple red/red corvette joystick armor cover (K0108), for the enrollee.
You asked the Plan to pre-approve the item. You say that you are requesting review of denial of services. The Plan denied your request. The Plan says this item is not considered to be primarily medical in nature and as such are not covered by Medicare.
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 candy apple red/red corvette joystick armor cover (K0108), for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional occupational therapy visits.
You asked the Plan to pre-approve additional occupational therapy visits. You say that the enrollee would
benefit from continued therapy to address safety during functional tasks while reaching, bending and
ambulating. The Plan denied your request. The Plan says continued therapy is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient
therapy.
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 occupational therapy visits.
Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent
deterioration of the enrollee's condition. Our physician reviewer found that the enrollee has had extensive
therapy. Our reviewer says that the remaining deficits do not require the unique skills of a professional
therapist to safely and effectively provide ongoing treatment.
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 occupational therapy visits have not been met. Therefore, we decided
that the Plan does not have to pre-approve additional occupational therapy visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor.
You asked the Plan to pre-approve a continuous glucose monitor. You say that you are unable to do finger
sticks and want a continuous glucose monitor to monitor your blood sugar properly. The Plan denied your
request. The Plan says criteria are not met for a continuous glucose monitor.
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. You are not insulin treated so you do not meet the Medicare coverage
criteria for a CGM. Based on this information, we decided that Medicare rules for coverage of a 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the foot inserts (L3020 x 2).
You asked the Plan to pre-approve foot orthotics. You say that you have tendonitis on your Achilles tendons of both ankles. The Plan denied your request. The Plan says the medical records do not show that requested orthotics will be used for proper functioning of a leg brace.
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 the foot inserts (L3020 x 2).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 10 additional physical therapy visits.
You asked the Plan to pre-approve 10 additional physical therapy visits. You say that additional physical therapy visits are medically necessary. The Plan denied your request. The Plan says additional visits are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 10 additional physical therapy visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found that the enrollee had extensive therapy and was trained in a home exercise program. Our reviewer says that the unique skills of a professional therapist are not required to safely and effectively provide ongoing treatment. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 10 additional physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 10 additional physical therapy visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor.
You asked the Plan to pre-approve a continuous glucose monitor. You say that the enrollee needs a continuous
glucose monitor. The Plan denied your request. The Plan says criteria for a continuous glucose monitor are not
met.
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. The record shows the enrollee is not insulin treated therefore the
Medicare coverage criteria for a CGM is not met. Therefore, we decided that the Plan does not have to preapprove
a continuous glucose monitor.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a genital surgery procedure (55899).
You asked the Plan to pre-approve the surgery procedure. You say that you would like reconsideration because this service is medically necessary. The Plan denied your request. The Plan says CPT code 558766 for surgery is approved and includes robotic assistance if used so the requested procedure is duplicative.
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 55899 is not supported in the record. Specifically, the surgery has been approved so CPT code 55899 is duplicative. Based on this information, we decided that Medicare rules for coverage of the surgery procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve a genital surgery procedure (55899).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve BRCA genetic testing.
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 you do not meet the criteria for coverage.
The Plan must follow Medicare rules. Medicare rules say that BRCA testing is covered for a beneficiary with a current diagnosis or a personal history of a cancer associated with the BRCA mutation who meets specific criteria. We looked at the file and Medicare rules. The file shows that you do not have a personal history of cancer for which BRCA testing is covered. 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 BRCA genetic testing.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient transcatheter aortic valve replacement
(TAVR).
You asked the Plan to pre-approve inpatient TAVR. You say that please review the enclosed medical records,
FDA approval, clinical research and please review the minutes from the interdisciplinary conference. The Plan
denied your request. The Plan says the documentation does not support that this request meets the criteria.
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 inpatient TAVR. Our reviewer says that
the requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found based on the records the enrollee has severe symptomatic bicuspid aortic valve stenosis and
reported low surgical risk. In this circumstance NCD criteria are not met since there is no transcatheter valve
replacement that is approved for use in low surgical risk enrollee with bicuspid aortic valves. For this reason,
one of the multidisciplinary valve team members leaned toward recommending surgical aortic valve
replacement upon initial evaluation.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of inpatient TAVR have not been met. Therefore, we decided that the Plan does
not have to pre-approve inpatient transcatheter aortic valve replacement (TAVR).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 6 additional occupational therapy visits.
You asked the Plan to pre-approve 6 additional occupational therapy visits. You submitted additional documentation appealing the denial for additional visits. The Plan denied your request. The Plan says additional therapy visits are not reasonable and necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 6 additional occupational therapy visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found that the enrollee had prior therapy and is compliant in a home exercise program. Our reviewer says that the unique skills of a professional therapist are not required to safely and effectively provide ongoing treatment. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 6 additional occupational therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 6 additional occupational therapy visits.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 6 additional occupational therapy visits.
You asked the Plan to pre-approve 6 additional occupational therapy visits. You say that the enrollee will be being discharged soon and you want to make sure there are enough visits. The Plan denied your request. The Plan says additional visits are not reasonable and necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 6 additional occupational therapy visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the enrollee had 10 occupational therapy visits with minimal objective gains. Our reviewer says that the unique skills of a professional therapist are not required to safely and effectively provide ongoing treatment. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 6 additional occupational therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 6 additional occupational therapy visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genicular RFA.
You asked the Plan to pre-approve the genicular RFA. You say that you would like reconsideration because
this service is medically necessary. The Plan denied your request. The Plan says this is not a proven procedure
at this time.
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 genicular RFA. Our reviewer says
that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found there is insufficient evidence in the medical literature demonstrating the efficacy of
genicular radiofrequency ablation in the treatment of knee pain following total knee arthroplasty.
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 genicular RFA have not been met. Therefore, we decided that the Plan does
not have to pre-approve genicular RFA.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve personal care attendant services.
You asked the Plan to pre-approve personal care attendant services. You say that you would like the Plan to
reconsider their denial. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that Custodial care is not covered.
We looked at the file and Medicare rules. In this case, personal care attendant services are being requested.
Personal care attendant services are considered custodial care, which includes care that helps people with
activities of daily living, like walking, getting in and out of bed, bathing, dressing, eating, personal hygiene,
and supervision of special diets and medications. Custodial care is not covered under Medicare or the Plan.
Based on this information, we decided that Medicare rules for coverage of personal care attendant services
have not been met. Therefore, we decided that the Plan does not have to pre-approve personal care attendant
services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Superior spacer device.
You asked the Plan to pre-approve a Superior spacer device. 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 Superior spacer device. Our reviewer
says that the requested services are not considered medically reasonable and necessary in this case. Our
physician reviewer found that the Superior spacer device is experimental and more research is needed.
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 Superior spacer device have not been met. Therefore, we decided that the Plan
does not have to pre-approve a Superior spacer device.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve SNF care.
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied
your request. The Plan says that the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed above are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve SNF care. Our physician reviewer
found this patient does not require skilled nursing services, i.e., are the specialized skill, knowledge and
judgment of a skilled professional nurse required to safely and effectively provide medically necessary and
reasonable treatment. This patient requires skilled therapy services, i.e., are the specialized skill, knowledge
and judgment of a qualified therapist required to safely and effectively provide medically necessary and
reasonable treatment. The documentation supports that it is medically reasonable and necessary to provide
skilled therapy services on a "daily basis". This patient requires the necessary services on an inpatient basis, in
a skilled nursing facility setting.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of SNF care have been met. The Plan must continue coverage for the SNF skilled
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve SNF care.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuous glucose monitor (CGM) supplies.
You asked the Plan to pre-approve the CGM supplies. The Plan denied your request. The Plan says the
requested items are not covered benefits.
The Plan must follow Medicare rules. Medicare rules say that coverage of continuous glucose monitors
(CGMs) is limited to therapeutic CGMs.
We looked at the file and Medicare rules. The records show that you are asking for coverage of CGM supplies
to be used with a Medtronic MiniMed 670G system or a MiniMed 630G system. These Medtronic CGMs are
not therapeutic CGMs. Based on this information, we decided that Medicare rules for coverage of the CGM
supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve continuous
glucose monitor (CGM) supplies.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hydroxychloroquine Sulfate.
You asked the Plan to pre-approve the Hydroxychloroquine Sulfate. You say that the enrollee's condition is a
covered indication. The Plan denied your request. The Plan says this drug is not covered for the enrollee's
condition by Medicare Part B.
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 Hydroxychloroquine
Sulfate.
Benefits for the Hydroxychloroquine Sulfate 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the portable x-ray services (71045) provided on February 27,
2020.
You asked the Plan to pay for the portable x-ray services. You say that the service was medically necessary.
The Plan denied your request. The Plan says the out-of-network service was not pre-authorized.
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 pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
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. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for the portable x-ray services (71045) provided on
February 27, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for emergency room services provided out of the country on November 9, 2019.
You asked the Plan to reimburse you for ambulance and emergency room services while out of the country. The Plan denied part of your request. The Plan says you submitted proof of payment for your Ambulance services and the Plan is reimbursing you for the allowable costs. However, you stated you lost your receipt for the emergency room services, and to process those services for reimbursement, the Plan must have receipt of payment.
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 have receipts and proof of payment for services provided out of the country. While the Plan has reimbursed the ambulance services, they cannot reimburse the emergency room services without proof of payment. Therefore, we decided that the Plan does not have to reimburse you for ambulance and emergency room services provided out of the country on November 9, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for medical services provided to the enrollee on February 23,
2020 under code 80170.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your
request. The Plan says Medicare billing criteria were not met.
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 secondary diagnosis code is
being listed as the primary diagnosis code which in not appropriate based on the Medicare billing guidelines.
This error has prevented payment of the claim. Based on this information, we decided that Medicare rules for
coverage of this service have not been met. Therefore, we decided that the Plan does not have to pay for
medical services provided to the enrollee on February 23, 2020 under code 80170.