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

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that the orthotics help support your back and hips so 
they don't go out of whack. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide an ultralightweight wheelchair heavy duty package.
You asked the Plan to provide an ultralightweight wheelchair heavy duty package. You say that the
ultralightweight wheelchair that was approved will not accommodate you. The Plan denied your request. The
Plan says the heavy duty package is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code. In this case, we have confirmed that a manual
wheelchair heavy duty package has a bundled relationship with code K0005 and cannot be provided as
requested. This code cannot be provided as a separate line item. Therefore, we decided that the Plan does not
have to provide an ultralightweight wheelchair heavy duty package.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Superion Indirect Decompression System.
You asked the Plan to pre-approve a Superion Indirect Decompression System. You say that the insertion of a lumbar interspinous spacer would provide significant clinical and quality of life benefits for the enrollee. You say that the requested treatment is medically necessary for the stage of the disease progression. The Plan denied your request. The Plan says medical studies haven't proven that the device is helpful for treatment of the enrollee's health problem.
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 Superion Indirect Decompression System. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the spacer remains experimental. Our physician reviewer found that more research is needed to show the safety and efficacy of the device. 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 Superion Indirect Decompression System have not been met. Therefore, we decided that the Plan does not have to pre-approve a Superion Indirect Decompression System.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve MTHFR testing. 
 
You asked the Plan to pre-approve MTHFR testing. 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 testing. 
 
The Plan must follow Medicare rules. Medicare rules say that MTHFR testing is only covered for certain 
indications. 
 
We looked at the file and Medicare rules. Review of the file does not support that you have completed pedigree 
analysis and genetic counseling. Based on this information, we decided that Medicare rules for coverage of 
MTHFR testing have not been met. Therefore, we decided that the Plan does not have to pre-approve MTHFR 
testing.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home oxygen concentrator cart/tank.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the treating condition is not a breathing-related condition.
The Plan must follow Medicare rules. The rules say that to qualify for portable oxygen, the patient must meet the criteria for home oxygen. The documentation must show that the patient is mobile in the home and would benefit from the use of portable oxygen in the home. Portable oxygen is not covered for patients who qualify for oxygen solely based on blood gas studies obtained during sleep. To qualify for home oxygen, the patient must meet one of the following blood gas levels: 1. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, at rest; 2. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, taken during sleep for a patient who have hypoxia symptoms during sleep; 3. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88%, taken during exercise for
patients who have hypoxia symptoms during exercise; 4. Arterial PO2 between 56 and 59 mmHg and arterial O2 saturation is 89% on room air if there is evidence of dependent edema, pulmonary hypertension, or erythrocythemia. For patients with arterial PO2 at or above 60 mm Hg or arterial O2 saturation at or above 90% on room air, there is a rebuttable presumption of non-coverage. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found you apparently have a GI issue, and intermittent oxygen therapy has been prescribed as an experimental treatment, in the ordering physician's words. Medicare does not cover treatments that are experimental. There is no evidence in the records of hypoxemia. Home oxygen is considered 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 the services have not been met. Therefore, we decided that the Plan does not have to pre-approve a home oxygen concentrator cart/tank.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the complete lower denture (D5120). 
 
You asked the Plan to pre-approve the complete lower denture (D5120). You say that the immediate denture 
cannot keep being adjusted. You say that a complete denture is needed. The Plan denied your request. The Plan 
says only one of D5120, D5140, D5212 or D5214 are covered per 60 months per patient. 
 
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 of D5120, D5140, D5212 or D5214 per 60 months. The Plan paid for an immediate lower denture 
(D5140) provided on January 10, 2020, which exhausted the benefit. Therefore, we decided that the Plan does 
not have to pre-approve the complete lower denture (D5120).
Appeal type: Outpatient Mental Health
Decision: Favorable

 
We decided that the Plan has to pre-approve transcranial magnetic stimulation (TMS) treatment services. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee has participated in multiple 
medication trials, which have not helped. The Plan denied your request. The Plan says that the enrollee can be 
treated with medication management and psychotherapy. 
 
The Plan follows Medicare rules. Medicare rules say that Transcranial Magnetic Stimulation is only covered 
under certain medical indications.  
 
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 requested services. Our physician 
reviewer found that the enrollee has tried Rmeron, Effexor, Rexulti, Xanax, Tegretol, Abilify, Topamax, and 
Zyprexa. She has been seeing a therapist since 2015. Her PHQ 9 score was noted to be 20. Coverage rules 
require the confirmed diagnosis to be Severe Major Depressive Disorder Single or Recurrent, resistance to the 
treatment with pharmacologic agents, as evidenced by lack of clinical significant response to pharmacologic 
agents from at least two different agent classes, along with concurrent documented psychotherapy. This 
enrollee does possess the diagnosis as noted above. She had been tried on pharmacologic agents from different 
categories, for which she has had very little improvement. She is not desiring electroconvulsive treatment. 
Based on the records provided, the enrollee does meet the criteria for the requested 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 the requested services have been met. Therefore, we decided that the Plan has to 
pre-approve transcranial magnetic stimulation (TMS) treatment services.  
 
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the core buildup (D2950).
You asked the Plan to pre-approve the core buildup (D2950). The Plan denied your request. The Plan says the service is not a covered benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the core buildup (D2950).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics (L3020). 
 
You asked the Plan to pre-approve foot orthotics. You say that the foot orthotics are medically necessary. 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 (L3020).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a follow-up visit to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve a follow-up office visit. You say that you would like to go to the same doctor that did your surgery. The Plan denied your request. The Plan says there are in-network providers available for these services.
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 a follow-up visit to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Continuous Glucose Monitor (CGM) with supplies (K0554 K0553).
You asked the Plan to pre-approve the CGM. You say that a CGM 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 for a CGM to be covered, the beneficiary must be insulin-treated with multiple (three or more) daily injections of insulin. We looked at the file and Medicare rules. The record does not show that the enrollee injects insulin. Based on this information, we decided that Medicare rules for coverage of the CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a Continuous Glucose Monitor (CGM) with supplies (K0554 K0553).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve adult sized, protective underwear/pull-on (T4526) disposable liner/ shield/ guard/ pad/ undergarment (T4535) and protective under pad, reusable (T4537).
You asked the Plan to pre-approve incontinence supplies. You say that you do not have enough funds to purchase the supplies. The Plan denied your request. The Plan says these items is not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve adult sized, protective underwear/pull-on (T4526) disposable liner/ shield/ guard/ pad/ undergarment (T4535) and protective under pad, reusable (T4537).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete mandibular denture.
You asked the Plan to pre-approve the complete mandibular denture. The Plan denied your request. The Plan
says this service is allowed one time every 60 months. The Plan also says that you had this service less than 60
months ago.
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, dentures are limited to one set every 5
years. The record shows that you received a complete mandibular denture on October 20, 2016, and your
mandibular dentures benefit has been exhausted. Therefore, we decided that the Plan does not have to preapprove
a complete mandibular denture.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair.
You asked the Plan to pre-approve a power wheelchair. You say that your current power wheelchair is not
operational and now you stay in your room. The Plan denied your request. The Plan says Medicare does not
provide power wheelchairs for long term care residents.
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 to be a home.
Records show that a power wheelchair is being requested for use in a SNF. Therefore, we decided that the Plan
does not have to pre-approve a power wheelchair.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is not clinically appropriate 
for a lower level of care. The Plan denied your request. The Plan says the enrollee is receiving appropriate care 
at the current acute care facility. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our physician 
reviewer found that LTACHs are certified as acute care hospitals, and in general, LTACHs do not provide 
clinical services that are materially different than those of short term acute care hospitals. In this case, ongoing 
care needs include respiratory support with tracheostomy care, suctioning, surgical wound care, surveillance 
laboratory studies, tube feeding, and therapy services. The documentation does not support that the enrollee in 
this case requires services at the LTACH that are not available at the acute care hospital where he is currently 
receiving care. There are no required medical services identified that are available at the LTACH, that are not 
available at the current health care setting being offered by the health plan. Consequently, the requested 
LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of 
the enrollee at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve reclining sofa/chair (A9999).
You asked the Plan to pre-approve reclining sofa/chair. You say that the medical records provided will show
proof of medical necessity. The Plan denied your request. The Plan says this is not a covered benefit
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 reclining sofa/chair (A9999).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the oral tissue biopsy (D7286).
You asked the Plan to pre-approve the oral tissue biopsy (D7286). You say that you need the incisional biopsy. You say that you don't have the means for it. The Plan denied your request. The Plan says the service is not a covered benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the oral tissue biopsy (D7286).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Trulicity (J3490) for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says Medicare says Part B programs can only provide limited benefits for prescription drugs.
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 Trulicity (J3490) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve tie down hardware, footplate with bracket, expandable controller and expandable controller harness.
You asked the Plan to pre-approve these items. You say that these items are medically necessary. The Plan denied your request. The Plan says that these items are not coverable.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. 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 rules also say that when one power seating function/actuator/motor is provided on a power wheelchair an expandable controller and harness are not allowed in this situation. The tie down hardware 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.
The file shows that you were approved for a power tilt seating system. The system includes footplates. The power tilt seating system footplates serve the same purpose as the footplate with bracket.
The file also shows that one power seating function is being requested. Therefore, an expandable controller and harness are not allowed in this situation.
Therefore, we decided that the Plan does not have to pre-approve tie down hardware, footplate with bracket, expandable controller and expandable controller harness.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CT scan of the chest. 
 
You asked the Plan to pre-approve a CT scan of the chest. You say that the requested CT scan of the chest is 
medically necessary. The Plan denied your request. The Plan says the requested CT scan of the chest is not 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT 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 a CT scan of the chest. Our reviewer 
says that the requested CT scan of the chest is not medically necessary. Our physician reviewer found there is 
no supporting information in the record to justify a CT of the chest.  Emphysema noted is a chronic condition 
and there was no reference to an acute worsening or a reason for the imaging study. No documentation to 
support imaging study provided has been provided for review. 
 
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 CT scan of the chest have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CT scan of the chest.