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

We decided that the Plan does not have to pre-approve Spravato 56mg solution.

You asked the Plan to pre-approve Spravato. You say that Spravato is medically necessary. The Plan denied
your request. The Plan says this medication is not eligible for coverage under the Part B medical benefit.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 Spravato 56mg solution.

Benefits for Spravato 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: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the services provided on February 14, 2020.You asked the Plan to pay for the services. The Plan denied your request. The Plan says that the services were billed incorrectly.The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan has not submitted a valid denial rationale. Without a valid rationale, the Plan's denial cannot be substantiated.Therefore, we decided that the Plan has to pay for the services provided on February 14, 2020.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 provide a continuous glucose monitoring (CGM) system.You asked the Plan to provide a CGM system. You say that you tried a CGM and it has effectively and efficiently allowed you to maintain your glucose levels.The Plan denied your request. The Plan says you do not meet criteria for a CGM.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 you do not use insulin with at least three daily injections nor require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of a CGM system have not been met.Therefore, we decided that the Plan does not have to provide a continuous glucose monitoring (CGM) system.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for occupational therapy services (97167) provided on June 18, 2020.You asked the Plan to pay for occupational therapy services. You say that this should be covered.The Plan denied your request. The Plan says this was not billed correctly.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 97167 is occupational therapy evaluation, high complexity, requiring these components: An occupational profile and medical and therapy history,which includes review of medical and/or therapy records and extensive additional review of physical, cognitive, or psychosocial history related to current functional performance; An assessment(s) that identifies 5 or more performance deficits (i.e., relating to physical, cognitive, or psychosocial skills) that result in activity 
limitations and/or participation restrictions; and Clinical decision making of high analytic complexity, which includes an analysis of the patient profile, analysis of data from comprehensive assessment(s), and consideration of multiple treatment options. Patient presents with comorbidities that affect occupational performance. Significant modification of tasks or assistance (e.g., physical or verbal) with assessment(s) is necessary to enable patient to complete evaluation component. Typically, 60 minutes are spent face-to-face with the patient and/or family.We find that CPT code 97167 is not supported in the medical record. Specifically, the record shows that this service was provided in a home health setting. There is a more appropriate code for this service. Based on this information, we decided that Medicare rules for coverage of occupational therapy services have not been met.Therefore, we decided that the Plan does not have to pay for occupational therapy services (97167) provided on June 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 3 power wheelchair and accessories.You asked the Plan to pre-approve a group 3 power wheelchair and accessories. You say that this request is medically necessary.The Plan denied your request. The Plan says the criteria for a group 3 power wheelchair have not been met.The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for enrollees who have a mobility limitation that is due to:1. A neurological condition;2. Myopathy; or3. Congenital skeletal deformity.The file does not show that you have a mobility limitation that is due to a neurological condition, myopathy or congenital skeletal deformity.Therefore, we decided that the Plan does not have to pre-approve a group 3 power wheelchair and accessories.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a continuous glucose monitor (K0553, K0554).You asked the Plan to pay for 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 insulin with at least three daily 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 pay for a continuous glucose monitor (K0553, K0554).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the neuromuscular stimulator and supplies (E0745, A4595) to be provided by an out of network (OON) provider.You asked the Plan to pre-approve the neuromuscular stimulator and supplies. You say that the device is being prescribed to improve arterial inflow to lower extremity, prevent venous stasis and DVT, and reduce edema/swelling of lower extremity. You feel this decision should be reversed.The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.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 the neuromuscular stimulator and supplies (E0745, A4595) to be provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 2 retainer crowns (D6751) and a pontic (D6241).
You asked the Plan to pre-approve the bridge. You say that you are not looking for a full mouth of teeth. You
say that you just want what is broken or missing in the front to be fixed. You also say that this will be the only
time that you will need to use your dental coverage this year. The Plan denied your request. The Plan says
bridge is not listed as a covered service.
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 2
retainer crowns (D6751) and a pontic (D6241).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), prophylaxis (D1110), the periapical x-ray (D0220), and the unspecified preventive service (D1999) provided on January 28, 2021.
You asked the Plan to pay for the dental services. You say that the services should be covered. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan says that dental services performed out of network are not covered. The Plan also says that the services could have been provided in network.
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 periodic oral evaluation (D0120), prophylaxis (D1110), the periapical x-ray (D0220), and the unspecified preventive service (D1999) provided on January 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve pulmonary artery pressure sensor device (33289, C2624).
You asked the Plan to pre-approve pulmonary artery pressure sensor device. You say that the CardioMEMS System is indicated for wirelessly measuring and monitoring pulmonary artery pressure and heart rate in Heart Association Class Ill heart failure patients who have been hospitalized for heart failure in the previous year. The Plan denied your request. The Plan says this device is experimental and investigational. This device is unproven and untried for heart problems.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The rules also say that experimental and investigational devices are not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of pulmonary artery pressure sensor device have not been met. Therefore, we decided that the Plan does not have to pre-approve pulmonary artery pressure sensor device (33289, C2624).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ensure, enteral formula, nutritionally complete with intact nutrients (B1450).You asked the Plan to pre-approve supplemental nutrition. You say that it is your medical opinion that a patient with this problem should receive nutrition products to prevent malnutrition.The Plan denied your request. The Plan says Medicare does not cover nutritional supplementation.The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation.The items you asked the Plan to pre-approve are considered nutritional supplements. Although these may be appropriate, neither Medicare nor the Plan provides coverage for them.Therefore, we decided that the Plan does not have to pre-approve Ensure, enteral formula, nutritionally complete with intact nutrients (B1450).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the test materials and equipment for home INR monitoring to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the test materials and equipment . You say that you require at home monitoring as prescribed by your physician for multiple clots and a triple bypass procedure that you underwent about 4 years ago. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
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
the test materials and equipment for home INR monitoring to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (99308) provided on November 23, 2020.You asked the Plan to pay for the services. The Plan denied your request. The Plan says this service is not payable.The Plan must follow Medicare rules. Medicare rules say that if a provider reports the two codes of an edit pair, the column two code is denied, and the column one code is eligible for payment. Procedure code 99308 is part of an edit pair with procedure code 99309. Procedure code 99309 is a column one code, and procedure code 99308 is a column two code. Procedure code 99309 has been for this date of service, which means that procedure code 99308 is not eligible for payment.Therefore, we decided that the Plan does not have to pay for the services (99308) provided on November 23, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a heavy duty extra wide hospital bed.
You asked the Plan to pre-approve a heavy duty extra wide hospital bed. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says you do not meet criteria for the requested item.
The Plan must follow Medicare rules. Medicare rules say that a heavy duty extra wide hospital bed (E0301, E0303) is covered if the beneficiary meets one of the criteria for a fixed height hospital bed and the beneficiary's weight is more than 350 pounds, but does not exceed 600 pounds. We looked at the file and Medicare rules. Review of the file does not support that you weigh more than 350 pounds. Based on this information, we decided that Medicare rules for coverage of a heavy duty extra wide hospital bed have not been met. Therefore, we decided that the Plan does not have to pre-approve a heavy duty extra wide hospital bed.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core build up (D2950) for tooth # 20.
You asked the Plan to pre-approve the dental service. You say that this service is necessary. The Plan denied
your request. The Plan says core build up is not listed as a covered service.
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 core
build up (D2950) for tooth # 20.
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 the enrollee meets the criteria for care at an IRF. She has rehab goals for her current needs relating to a fall which resulted in fractures. She requires pain control, physical and occupational therapy, and management for chronic conditions.The Plan denied your request. The Plan says the criteria for IRF are not met. Based upon the enrollee's current level of function, an intensive, complex, multidisciplinary approach to daily therapy is not required.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute inpatient stay with an interdisciplinary approach to rehabilitation care. Medical conditions are stable and there are no complex nursing or rehabilitation needs. The enrollee does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve fabrication of an athletic mouthguard (D9941).
You asked the Plan to pre-approve an athletic mouthguard. You say that the mouth guard is medically
necessary. The Plan denied your request. The Plan says this service is not covered under your 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
fabrication of an athletic mouthguard (D9941).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient hospital care to be provided after right shoulder arthroplasty.You asked the Plan to pre-approve acute inpatient hospital care.The Plan denied your request. The Plan says there is no documentation provided to support the expectation the enrollee will require a greater than a two midnight stay.The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient care are met in this case. 
Our physician reviewer found that the enrollee is a 66-year-old male with past medical history of hypertension, cerebrovascular accident, atrial fibrillation and non-specific bleeding disorder who presents with chronic, debilitating right shoulder pain secondary to end-staged osteoarthritis. The enrollee has tried and failed conservative treatments. The enrollee has been approved for aright shoulder arthroplasty.The enrollee is medically stable and has been provided medical clearance to undergo this elective procedure. The planned procedure listed under CPT code 23472 is not listed on the CMS Inpatient Only List. The procedure is currently approved as an ambulatory procedure. There is no documentation provided to support the expectation the enrollee will require a greater than two midnight stay. The review has determined that the record does not show that the admitting physician reasonably expects that the enrollee's necessary hospital care will span two midnights.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met.Therefore, we decided that the Plan does not have to pre-approve acute inpatient hospital care to be provided after right shoulder arthroplasty.
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. The Plan denied your request. The Plan says the enrollee does not require physician supervision 3 times a week.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 physician reviewer found that the enrollee was admitted to the acute care hospital for surgical repair of a hip fracture after a fall. Her medical conditions are stable. There are no complex nursing needs. She does not require treatment by multiple therapies, including either physical or occupational therapy, and 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.