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

We decided that the Plan does not have to provide a power mobility device.
You asked the Plan to provide a power mobility device. You say that because of a medical condition the
enrollee needs a power mobility device. The Plan denied your request. The Plan says they made multiple
attempts to obtain the home assessment but it was not submitted.
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.
The file does not show that the enrollee can safely operate the PMD being requested. There is no home
assessment documentation. This means that Medicare rules for coverage of a PMD have not been met.
Therefore, we decided that the Plan does not have to provide a power mobility device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for ankle foot orthosis (L1971), foot, plastic, silicone or equal,
heel stabilizer, prefabricated, off-the-shelf, each (L3170) and wrist hand orthosis (L3916) provided to the
enrollee on February 24, 2020.
You asked the Plan to pay for the orthoses. You say that the durable medical equipment is medically necessary.
The Plan denied your request. The Plan says documentation indicates services are not necessary for treatment
of the enrollee's condition.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services,
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for
telehealth services only if they are presented from an authorized originating site located in either a county
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located
in a rural census tract.
A review of the file does not show that the telehealth service was provided in an authorized originating site.
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are
likewise noncovered. Therefore, we decided that the Plan does not have to pay for ankle foot orthosis (L1971),
foot, plastic, silicone or equal, heel stabilizer, prefabricated, off-the-shelf, each (L3170) and wrist hand orthosis
(L3916) provided to the enrollee on February 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (D2751) for tooth #25
You asked the Plan to pre-approve the crown. You say that there was a root canal done on tooth #25, and a
crown is recommended. The Plan denied your request. The Plan says the tooth does not appear to have
significant breakdown due to decay or trauma.
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. The Plan covers the crown
when the services are medically necessary and reasonable.
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 crown. Our reviewer says that the
service is not medically necessary. Our physician reviewer found the documentation provided indicates that
tooth #25 has a poor prognosis for retention due to the severe bone loss. Our reviewer also found that the
criteria for coverage for a crown have not been met.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
the Plan's rules for coverage of the crown have not been met. Therefore, we decided that the Plan does not have
to pre-approve a crown (D2751) for tooth #25
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve routine foot care once every five weeks.
You asked the Plan to pre-approve routine foot care once every five weeks. You say that you have severe pain
between appointments. The Plan denied your request. The Plan says these services cannot be covered more
than once every sixty days.
The Plan must follow Medicare rules. Medicare rules say that routine foot care services are considered
medically necessary once in 60 days.
We looked at the file and Medicare rules. Routine foot care is only considered reasonable and necessary one
every 60 days. More frequent services are not covered by Medicare. Based on this information, we decided that
Medicare rules for coverage of routine foot care once every five weeks have not been met. Therefore, we
decided that the Plan does not have to pre-approve routine foot care once every five weeks.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve non-invasive interface, home ventilator (E0466).
You asked the Plan to pre-approve non-invasive interface, home ventilator. You say that please see the attached
requesting appeal for home Trilogy. With Trilogy at home the enrollee would have improved mortality and less
risk of hospital readmission. The Plan denied your request. The Plan says the medical records submitted did not
support the medical necessity required to approve the request for home ventilator with non-invasive interfaces.
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory
failure due to COPD.
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 non-invasive interface, home ventilator.
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in
this case. Our physician reviewer found the coverage criteria for a home ventilator are not met. This enrollee
has severe COPD, with a recent hospitalization with a COPD exacerbation and acute-on-chronic hypercarbic
respiratory failure. The enrollee may benefit from BiPAP at night. However, Medicare does not cover a home
ventilator when used as BiPAP. There is no evidence of BiPAP failure. Certain BiPAP devices are capable of
providing the AVAPS-AE mode of support that has been ordered. A home ventilator is not medically
necessary, and the denial is upheld.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of non-invasive interface, home ventilator have not been met. Therefore, we
decided that the Plan does not have to pre-approve non-invasive interface, home ventilator (E0466).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power mobility device.
You asked the Plan to pre-approve a power mobility device. You say that the enrollee has knee pain and is
unable to walk far or shop. The Plan denied your request. The Plan says the medical records do not indicate the
enrollee has any type of mobility deficit that requires assistive devices.
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.
The file does not show the enrollee has a mobility deficit that impairs participation in MRADLs or that the
enrollee's condition cannot be improved by a walker, cane or manual wheelchair. This means that Medicare
rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to preapprove
a power mobility device.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Herceptin.
You asked the Plan to pre-approve Herceptin. You say that you would like the plan to reconsider their denial.
The Plan denied your request. The Plan says that the requested drug is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer
drugs if they are medically accepted as safe and effective or appropriate for the particular use.
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 Herceptin. Our reviewer says that the
documentation supports that the requested drug is medically reasonable and necessary. Our physician reviewer
found the enrollee has stage IIIC1 high grade serous carcinoma of the uterus HER2+. A CT scan showed
persistent disease. While this drug is not FDA-approved for the enrollee's diagnosis, the use is supported by one
of the major drug compendia or by clinical research that appears in a CMS-approved medical journal.
Therefore, the enrollee meets criteria for the requested drug.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Herceptin have been met. Therefore, we decided that the Plan has to preapprove
Herceptin.
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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission and services.
You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says there is no complex medical condition requiring close medical monitoring or need for skilled nursing.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF services. Our physician reviewer found that the enrollee's pain is controlled. She has a non-weight bearing status. The enrollee does not require skilled nursing services of a skilled professional nurse to safely and effectively provide medically necessary treatment in a SNF. She does not have complex wound care or other ongoing SNF level skilled nursing need. Her functional level does not require skilled therapy services of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment in a SNF. She does not require skilled nursing or skilled therapy services (or a combination of these services) on a daily basis in a SNF. As a practical matter, this patient does not require the necessary services on an inpatient basis, in a skilled nursing facility setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission and services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
You asked the Plan to pre-approve continued services. You say that the enrollee would improve with physical and occupational therapy if she had more care. The Plan denied your request. The Plan says the enrollee is unable to actively participate in therapy.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered. Continued SNF services beyond August 19, 2020, was requested for 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 continued services. Our physician reviewer found that from a nursing perspective, the enrollee had stable vital signs, and was treated for pain with effect. There are no identifiable skilled nursing service needs. Regarding rehab services, the enrollee was at a maximal assist to dependent level with functional mobility and activities of daily living. There are no identifiable skilled therapy service needs. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a SNF setting.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission and services.
You asked the Plan to pre-approve SNF services. You say that the enrollee lost some of her physical ability. The Plan denied your request. The Plan says daily skilled nursing and therapy are not reasonable or necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that from a nursing perspective, the enrollee received oral medications, and had stable vital signs. She was treated for acute psychosis and mood disorder. There are no identifiable skilled nursing service needs. Regarding rehab services, the enrollee is at a modified independent to supervision assist level with functional mobility. There are no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. She does not meet severity of illness or intensity of service criteria for an inpatient basis in a SNF setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission and services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission and services.
You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says the enrollee is at her new functional baseline.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF services. Our physician reviewer found that from a nursing perspective, the enrollee received oral medications, and had stable vital signs. There are no identifiable skilled nursing service needs. Regarding rehab services, the enrollee was at a minimal to maximal assist with bed mobility and transfers. She required varying assist with activities of daily living. Although there are identifiable skilled therapy service needs, she does not require skilled nursing or therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a SNF setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission and services.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve a high frequency chest wall oscillation device.
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says that you have not failed conventional treatment to manage secretions.
The Plan follows Medicare rules. Medicare rules say that high frequency chest wall oscillation devices are 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 you have a chronic cough and chest congestion. A computed tomography (CT) scan of the chest documents mild bronchiectasis. You are unable to tolerate manual percussion or use mouthpiece airway clearance devices, as documented in the medical record. The HFCWOD may help in clearing secretions. Therefore, the requested device is considered 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 requested services have been met. Therefore, we decided that the Plan has to pre-approve a high frequency chest wall oscillation device.
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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission and services.
You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says you are at a custodial level of care.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF services. Our physician reviewer found that from a nursing perspective, you have stable vital signs, and were treated for pain with effect. There are no identifiable skilled nursing service needs. Regarding rehab services, you are at a moderate assist level for bed mobility. You require varying assist with activities of daily living. Although there are identifiable skilled therapy service needs, you do not require skilled nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a SNF setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on September 24, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code cannot
be verified.
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the
medical record, his or her intent that the test be performed.
We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab
requisition stating exactly which testing was to be performed. 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 pay for the drug testing services provided on September 24, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for a Genvisc injection (J7320) provided on January 8, 2020.
You asked the Plan to pay for a Genvisc injection. You say that this was medically necessary. The Plan denied
your request. The Plan says this code is not supported in the records.
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 J7320 is Genvisc 850, inj, 1mg.
We find that CPT code J7320 is not supported in the medical record. Specifically, the records show that the
injection provided on this date of service was Synvisc (J7325). Based on this information, we decided that
Medicare rules for coverage of a Genvisc injection have not been met. Therefore, we decided that the Plan does
not have to pay for a Genvisc injection (J7320) provided on January 8, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa for the enrollee.
You asked the Plan to pre-approve Euflexxa. You say that this is medically necessary for the enrollee. The Plan
denied your request. The Plan says that they did not receive documentation supporting the medical necessity
for a step therapy exception.
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
Euflexxa is not medically reasonable and necessary for the enrollee in this case. The patient has not tried and
failed Orthovisc and Monovisc. There is no documentation provided indicating that Orthovisc and Monovisc
would likely be less effective and/or likely have adverse effects for the enrollee. Our physician reviewer found
that the enrollee's condition does not meet step therapy criteria for Euflexxa.
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 for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on December 5, 2019.
You asked the Plan to pay for drug test. You say that you have submitted a valid physician laboratory
requisition form. The Plan denied your request. The Plan says the denial of payment for this service is correct,
because the documentation submitted does not include a valid physician order for this test.
The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific
lab services is required for covered lab services.
We looked at the file and Medicare rules. The documentation submitted does not include a valid physician
order or clear intent to order the lab service billed on this claim. Based on this information, we decided that
Medicare rules for coverage of drug test have not been met. Therefore, we decided that the Plan does not have
to pay for drug testing provided on December 5, 2019.