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

We decided that the Plan does not have to pre-approve a hypoglossal nerve stimulator to treat your obstructive sleep apnea.You asked the Plan to pre-approve the requested services. You say that the implantation is medically necessary to treat your condition.The Plan denied your request. The Plan says better evidence is required to support the procedure.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 rules say that the insertion of a chest wall respiratory sensor electrode is a non-covered service. Because this is an integral part of the requested procedure, the services at a whole remain denied. Furthermore, a proposed draft for future rulings cannot be considered as they are not in effect at this time. 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 pre-approve a hypoglossal nerve stimulator to treat your obstructive sleep apnea.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa (J7323).
You asked the Plan to pre-approve Euflexxa. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the member does not meet the step-therapy exception requirements.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 Euflexxa. Our reviewer says that the provided medical records do not indicate that the member has tried and failed Orthovisc or Monovisc. Our physician reviewer found the records do not indicate that the Plan's required drugs would likely be less effective and/or likely have adverse effects for the member.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have to pre-approve Euflexxa (J7323).
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pre-approve Polysomnography (95811).You asked the Plan to pre-approve the Polysomnography. You say that the repeat Polysomnography is medically necessary. The Plan denied your request. The Plan says that the repeat sleep study will not help in clinical management or improve the member's health.The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 the Polysomnography. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found there is already a substantial air leak, and higher pressures may make this worse. Also, the emergence of central apneas is a concern.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 Polysomnography have been met. Therefore, we decided that the Plan has to pre-approve Polysomnography (95811). 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 youa letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Power Mobility Device (PMD) (K0813). You asked the Plan to pre-approve the PMD. You say that the Power Wheelchair is medically necessary.The Plan denied your request. The Plan says coverage criteria has not been met.The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the PMD. Our reviewer says that the Power Wheelchair is not medically necessary. Our physician reviewer found based on the provided medical records there is no documentation either in the history or physical exam that the patient has a personal mobility deficit.In the review of systems from the 10/22/19 and 10/28/19 office visit notes there is indication that the patient does not have any gait disturbance.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 PMD have not been met.Therefore, we decided that the Plan does not have to pre-approve a Power Mobility Device (PMD) (K0813).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a rollator with a seat accessory (E0143, E0156).You asked the Plan to pre-approve the rollator. You say that the rollator is medically necessary.The Plan denied your request. The Plan says similar equipment was provided in 2016.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 you have a wheelchair. A wheelchair serves the same purpose as the rollator. The plan record shows similar equipment was also provided in 2016. The reasonable useful life of such equipment is considered 5 years under Medicare rules.Therefore, we decided that the Plan does not have to pre-approve a rollator with a seat accessory (E0143, E0156).
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 your feet hurt all of the time. 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea complete maxillary denture and a complete mandibular denture.You asked the Plan to pre-approvethe complete maxillary and mandibular dentures. You say that this provider said that they are participating with the enrollee's plan. You also say that the enrollee is in need of new dentures.The Plan denied your request. The Plan says the records support that this provider is not contracted with the enrollee's plan. The Plan also says that the enrollee has no benefits for procedures that are performed by out-of-network providers.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 covered when they are received by an out-of-network provider.Therefore, we decided that the Plan does not have to pre-approvea complete maxillary denture and a complete mandibular denture.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea FreeStyle Libre continuous glucose monitoring system.You asked the Planto pre-approvea continuous glucose monitor. You say that the enrollee needs a continuous glucose monitoring system.The Plan denied your request. The Plan says the records show the enrollee is not on an insulin regimen.The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered only when they are medically reasonable and necessary and replace a blood glucose monitor.We looked at the file and Medicare rules. 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-approvea FreeStyle Libre continuous glucose monitoring system.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652).
You asked the Plan to pre-approve a pneumatic compression device. You say that the enrollee requires the device. The Plan denied your request. The Plan says there is no evidence of truncal swelling or a four week trial of the basic pump like Medicare criteria requires.
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required.
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (E0652).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe sleep study to be provided by the out of network provider.You asked the Plan to pre-approvethe physician services. The Plan denied your request. The Plan says the requested service can be provided in network. ThePlan says there is no evidence the enrollee was referred by their primary care physician (PCP) or any other participating provider to receive the service.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 pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has confirmed there are 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 nothave to pre-approvethe sleep study to be provided by the out of network provider
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a SoClean CPAP cleaner and sanitizer device.You asked the Plan to pre-approve a SoClean CPAP cleaner and sanitizer device. You say that the enrollee cleans the CPAP machine but does not feel its adequate.The Plan denied your request. The Plan says a SoClean machine is not medical equipment.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 SoClean CPAP cleaner and sanitizer device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

e decided that the Plan does not have to pre-approvea seat lift chair.You asked the Plan to pre-approvethe seat liftmechanism of a seat lift chair. You say that because of a shoulder condition you cannot get out of a chair.The Plan denied your request. The Plan says your diagnoses do not fall underthe qualifying conditions for coverage.The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions listed above are met.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the seat lift mechanism of a seat lift chair. have not been met.Therefore, we decided that the Plan does not have to pre-approvea seat lift chair.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve electroretinography and visual evoked potential testing.You asked the Plan to pre-approve these services. You say that the services are needed to prevent the enrollee from losing his eyesight.The Plan denied your request. The Plan says the services are not covered.The Plan must follow Medicare rules. The rules say that the use of ERG for either glaucoma diagnosis or management is considered investigational.We looked at the file and Medicare rules. The file shows that the services are requested for management of glaucomatic optic atrophy. Medicare does not cover these services for this diagnosis.Therefore, we decided that the Plan does not have to pre-approve electroretinography and visual evoked potential testing.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the crown for tooth #2 and crown lengthening procedure.You asked the Plan to pre-approve the crown for tooth #2 and crown lengthening procedure. You say that the crown became loose and fell out. You say that you were informed the crown could not be reattached.The Plan denied your request. The Plan says the crown is allowed one time every 60 months. The Plan also says that the crown lengthening is included with the crown and does not need a separate request.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 Plan also has a maximum benefit of one crown per tooth every 60 months. The Plan paid for a crown for tooth #2 on December 5, 2017, which exhausted your benefit.Therefore, we decided that the Plan does not have to pre-approve the crown for tooth #2 and crown lengthening procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora power seat elevation system (E2300), an expandable controller (E2377, E2313, and E2311), an armrest pouch (K0108), and a USB charger (K0108). You asked the Plan to pay fora power seat elevation system, an expandable controller, an armrest pouch, and a USB charger. You say that these items are medically necessary. The Plan denied your request. The Plan says these items are not covered by Medicare.The Plan follows Medicare rules. Medicare rules say that wheelchair accessories are only covered according to the above listed rules.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 pay for a power seat elevation system, an expandable controller, an armrest pouch, and a USB charger. Our reviewer says that these items are not medically necessary. Our physician reviewer found the requests are convenience related and not in line with medical standards. The expandable controller is not necessary to perform any of the above-mentioned wheelchair functions. The power seat elevation system, armrest pouch, and USB charger are not covered under Medicare. As such, the disputed accessories are 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 a power seat elevation system, an expandable controller, an armrest pouch, and a USB charger have not been met.Therefore, we decided that the Plan does not have to pay fora power seat elevation system (E2300), an expandable controller (E2377, E2313, and E2311), an armrest pouch (K0108), and a USB charger (K0108).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the power wheelchair custom seat cushion and positioning back cushion.You asked the Plan to pre-approve power wheelchair custom seat cushions (CPT E2609, E2621).You say that the enrollee needs custom seat cushions.The Plan denied your request. The Plan says the documentation does 
not indicate an asymmetric posture as required by the coverage criteria and the cushions are included in the facility per diem.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home. Records show that power wheelchair custom seat cushions (CPT E2609, E2621) are being requested for use in a SNF or hospital.Therefore, we decided that the Plan does not have to pre-approve a Group 3 very heavy duty power wheelchair and custom seat cushion and positioning back cushion.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.You asked the Plan to pre-approve a shower chair. You say that you have the tendency to fall due to past injuries. You say you have already fallen once and injured yourself. You state that the shower chair would give you security.The Plan denied your request. The Plan says this item is not a covered benefit.The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item.Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a PET/CT scan.You asked the Plan to pre-approve the PET/CT scan. You say that a positive PET will imply a malignancy and would change treatment. You say that the records provided support the need for the requested PET scan.The Plan denied your request. The Plan says the records provided do not show doctor's notes that tell about other tests the enrollee has had for this problem. The plan says that the records provided do not show what has been done to help you or an explanation as to why other tests cannot be done first. The plan says that the records do not demonstrate how this test will change the doctor's course of treatment.The Plan must follow Medicare rules. Medicare rules say that PET scans 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 the PET/CT scan. Our reviewer says that the requested PET/CT scan is not medically reasonable and necessary. Our physician reviewer found the enrollee has a neuropathy of indeterminate origin. Our physician reviewer found that there was no indication within the medical records provided that the enrollee has been diagnosed with cancer. Our physician reviewer found that there were no lab results or other imaging studies to suggest the presence of cancer (or evena paraneoplastic process). Our physician reviewer found that there is no evidence within the records that the enrollee has an active tumor. In as much, there would not be a need to perform a PET/CT scan to determine if an "invasive diagnostic or therapeutic procedure" was required. Our physician reviewer found that there is also no evidence of a need to perform a PET/CT scan to make arrangements for an "anti-tumor treatment". Our physician reviewer found that, given the absence of any prior laboratory or imaging evidence to support that the enrollee has an active tumor, it cannot be determined that the requested service would be 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 the PET/CT scan have not been met.Therefore, we decided that the Plan does not have to pre-approvea PET/CT scan.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve diabetic shoes (A5500) and inserts (A5512). You asked the Plan to pre-approve diabetic shoes and inserts. You say that you are an insulin dependent diabetic with peripheral neuropathy. Additionally, you say that you have experienced extreme pain and numbness in your feet.The Plan denied your request. The Plan says you do not meet Medicare criteria for coverage of diabetic shoes and inserts.Medicare rules state that supportive devices for the feet (such as diabetic shoes and inserts) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.  Per review of the case file, you do not meet Medicare criteria for coverage of diabetic shoes and inserts. Specifically, the medical records do not show that you have a previous amputation, foot ulceration, history of pre-ulcerative calluses, active calluses,foot deformity, or poor foot circulation. Although diabetic shoes and inserts may be appropriate for you, neither Medicare nor the Plan provides coverage of diabetic shoes and inserts for your condition.Therefore, we decided that the Plan does not have to pre-approve diabetic shoes (A5500) and inserts (A5512).