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

We decided that the Plan does not have to pre-approve a knee orthosis (L1843).
You asked the Plan to pre-approve knee orthosis, single upright, thigh and calf, with adjustable flexion and
extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus
adjustment, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit
a specific patient by an individual with expertise (L1843). You say that you need a knee orthosis. The Plan
denied your request. The Plan says the records do not show objective evidence of instability.
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 knee orthosis, single upright, thigh and
calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control,
with or without varus/valgus adjustment, prefabricated item that has been trimmed, bent, molded, assembled, or
otherwise customized to fit a specific patient by an individual with expertise (L1843). Our reviewer says that
the requested item is not considered medically reasonable and necessary in this case. Our physician reviewer
found the medical record states the enrollee has knee pain but his provider only states that there is osteoarthritis
but no objective examination to show any instability, ligamental laxity or deformity. There is no specific
clinical rationale for the requested knee orthosis. The requested orthosis is 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 knee orthosis, single upright, thigh and calf, with adjustable flexion and
extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus
adjustment, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit
a specific patient by an individual with expertise (L1843) have not been met. Therefore, we decided that the
Plan does not have to pre-approve a knee orthosis (L1843).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the imaging rendered on December 1, 2020. You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 78452 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 78452 is multiple single-photon emission computed tomography (SPECT) myocardial perfusion imaging studies with stress. We find that CPT code 78452 is not supported in the medical record. Specifically, there is no documentation of SPECT myocardial perfusion imaging. 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 pay for the imaging rendered on December 1, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ilumya.
You asked the Plan to pre-approve Ilumya. You say that this is medically necessary. The Plan denied your request. The Plan says step therapy requirements have not been met.
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 Ilumya. Our reviewer says that the requirements for coverage of Ilumya have not been met. Our physician reviewer found the Plan requires a trial of 2 of their preferred drugs, Humira, Rinvoq, Skyrizi, Actemra (subcutaneous), Cosentyx, Otezla, Xeljanz, XeljanzXR, Orencia (subcutaneous), and Enbrel, before they will approve the requested drug. It is documented that the enrollee has tried 1 of the required drugs, Enbrel. It is also noted that the enrollee "is unable to receive Enbrel due to insurance reasons." The documentation does not support that the Plan's other required drugs would likely be less effective or have adverse effects for the enrollee in this case. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Ilumya have not been met. Therefore, we decided that the Plan does not have to pre-approve Ilumya.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve intracept procedure.

You asked the Plan to pre-approve intracept procedure. You say that you feel this procedure fills a treatment gap for those enrollees that do not receive adequate relief from traditional conservative methods. The Plan denied your request. The Plan says the requested 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 intracept procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has low back pain. The enrollee has tried various conservative modalities. The intracept procedure remains experimental for low back pain. More research is needed. Therefore, the enrollee does not meet criteria for the requested services. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of intracept procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve intracept procedure.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the inpatient hospital services provided from November 22, 2020 to
November 27, 2020.
You asked the Plan to pay for the inpatient hospital services. You say that you would like the Plan to reconsider
their denial of payment. The Plan denied your request. The Plan says that the services are not covered.
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. In this case, the file shows that the Plan did not request from the provider
medical records from the first admission in order to determine if the Plan's reasoning for denial is correct based
on Medicare guidelines. Therefore, we decided that the Plan has to pay for the inpatient hospital services
provided from November 22, 2020 to November 27, 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve twelve (12) additional PT visits. 
 
You asked the Plan to pre-approve twelve (12) additional PT visits. You say that when you began PT sessions, 
you could not raise your arms enough to apply makeup, comb your hair, brush your teeth, wear button up shirts 
and pull shirts over your head, you were unable to prepare a meal and to chop foods, and even stirring things in 
a pan was impossible. The Plan denied your request. The Plan says additional PT 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 twelve (12) additional PT 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 additional requested therapy is not generally 
accepted as specific and effective therapy for your condition beyond what was approved by the health Plan. 
You have had prior therapy of at least thirty (30) outpatient visits and the records do not demonstrate that the 
unique skills of a professional therapist are required to safely and effectively provide treatment, that the 
services can be safely and effectively performed only by a therapist, or by or under the supervision of a 
therapist. You have been instructed in a home exercise program. The requested services are not part of a 
maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to 
establish, design and/or deliver a program to maintain your current condition or to prevent or slow further 
deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of twelve (12) additional PT visits have not been met. Therefore, we decided that 
the Plan does not have to pre-approve twelve (12) additional PT visits.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for Emergency Room services provided February 12, 2020 to February 15, 2020 in Mexico.
You asked the Plan to pay for the Emergency Room Services. You say that the services were medically necessary and should be covered. The Plan denied your request. The Plan says the claim must be paid up-front and submitted for reimbursement for services provided outside the United States.
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that enrollees have world-wide emergency coverage, however, claims must be paid up-front and then submitted for reimbursement. We looked at the plan contract, the file, and Medicare rules. The record does not show that the enrollee has paid the claim up-front. Based on this information, we decided that Medicare rules for coverage of the Emergency Room Services have not been met. Therefore, we decided that the Plan does not have to pay for Emergency Room services provided February 12, 2020 to February 15, 2020 in Mexico.
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 you disagree with the denial. The Plan denied your request. The Plan says the services are 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 services are not medically necessary. Our physician reviewer found the enrollee was admitted to the hospital for falls, rapid heartbeat (atrial fibrillation), and Parkinson's disease. He is now medically stable with no complex nursing or rehabilitation needs. He does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. He 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 the 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprove a Flexitouch continuous blood glucose monitor and supplies.
You asked the Plan to preapprove the continuous blood glucose monitor and supplies. You say that you feel that the continuous monitor is necessary, given your situation. The Plan denied your request. The Plan says you do not meet the requirements for coverage.
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 or 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 the
continuous blood glucose monitor and supplies have not been met. Therefore, we decided that the Plan does not
have to preapprove a Flexitouch continuous blood glucose monitor and supplies.
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 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 perform blood
glucose testing at least four times per day, 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 pre-approve a continuous glucose monitor.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy services rendered on February 18, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the provider type is not covered.
The Plan must follow Medicare rules. Medicare rules say that clinical psychology services must be provided by a clinical psychologist with a doctoral degree in psychology who is licensed and certified by the state. We looked at the file and Medicare rules. The file shows that the provider has an EdD (doctor of education) degree and not a doctorate in psychology. 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 pay for the psychotherapy services rendered on February 18, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment with Methylphenidate 20 mg tablet.
You asked the Plan to pre-approve Methylphenidate tablet. You say that the requested drug has been very effective and stopping the medication will result in relapse of negative symptoms. The Plan denied your request. The Plan says the requested drug is not covered by the Plan.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drug requested here is not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve treatment with Methylphenidate 20 mg tablet.
Benefits for Methylphenidate tablet 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 a semi-electric hospital bed (E0260).
You asked the Plan to pre-approve a semi-electric hospital bed. You say that this is necessary to alleviate pressure on your back sore. The Plan denied your request. The Plan says the records do not show you need frequent positioning changes.
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered medically necessary when the patient: 1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 2. Requires attachments which can only be attached to a hospital bed; AND 3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 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 semi-electric hospital bed. Our reviewer says that a semi-electric hospital bed is not medically necessary. Our physician reviewer found based on the medical records provided, there is no documentation that your condition requires positioning of the body in ways not feasible in an ordinary bed or that you require frequent or immediate changes in body position. There is no documentation that you require special attachments that cannot be fixed to and used on an ordinary bed. 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 semi-electric hospital bed have not been met. Therefore, we decided that the Plan does not have to pre-approve a semi-electric hospital bed (E0260).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a belt-strap-sleeve garment.
You asked the Plan to pre-approve a belt-strap-sleeve garment. You say that you feel the Plan should
reconsider offering some reasonable support while drainage is being done. The Plan denied your request. The
Plan says the requested item 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 belt-strap-sleeve garment. Our
reviewer says that the requested items/services are not considered medically reasonable and necessary in this
case. Our physician reviewer found you have a diagnosis of lymphedema of the right upper extremity. You
have a history of breast cancer and underwent a right radical mastectomy in 1974. You were evaluated by
Physical Occupational Therapy on June 17, 2021.
You have had increased swelling over several months and have had minimal reduction since initiating complete
decongestive therapy (CDT), despite good compliance with compression garment use, exercise, and selfmassage
due to the fibrotic lymphedema. It was determined that you would benefit from the use of a
compression pump or a device such as the AIROS 6 Sequential Compression Device. The documentation does
not support that you have a diagnosis/condition that meets criteria for the requested belt-strap-sleeve garment.
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 belt-strap-sleeve garment have not been met. Therefore, we decided that the
Plan does not have to pre-approve a belt-strap-sleeve garment
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on July 16, 2020.
You asked the Plan to pay for these services. You say that this claim should be paid by the Plan., The Plan denied your request. The Plan says while a portion of this claim was paid, the POS code reported on the claim prevents payment. The Plan states an independent lab must appropriately report what type of location the specimen was take from, for example from an inpatient our outpatient setting. The records provided show a discrepancy between the POS code reported and the place the specimen was obtained.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. In this case, this claim cannot be paid in its entirety due to an issue with the POS code recorded. The Plan states a corrected claim or additional information would be reviewed if submitted. Therefore, we decided that the Plan does not have to pay for lab services provided to the enrollee on July 16, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve oxygen. 
 
You asked the Plan to pre-approve oxygen. You say that you would like the plan to reconsider their denial. The 
Plan denied your request. The Plan says the requested oxygen is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that for patients with arterial PO2 at or above 60 mm Hg or 
arterial O2 saturation at or above 90%, there is a rebuttable presumption of non-coverage for home oxygen.   
 
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 oxygen. Our reviewer says that the 
documentation does not support that the requested oxygen is medically reasonable or necessary. Our physician 
reviewer found your oxygen saturation was 95% on March 30, 2021. The documentation includes a certificate 
of medically necessity showing a resting oxygen situation of 88% but that was in 2019. That does not appear to 
reflect your current status. There is no pulmonary or other diagnosis for which supplemental oxygen might be 
indicated. The medical records do not show a current medical necessity for home oxygen.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of oxygen have not been met. Therefore, we decided that the Plan does not have to 
pre-approve oxygen.