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

We decided that the Plan does not have to pre-approve vagus nerve stimulation.You asked the Plan to pre-approve the services. You say that you are requesting review of denial of services.The Plan denied your request. The Plan says the Medicare rules have not been met.The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. According to The Centers for Medicare and Medicaid Services (CMS) National Coverage Determination (NCD) for Vagus Nerve Stimulation (VNS) (160.18), vagal nerve stimulation is covered for the treatment of patients with medically refractory partial onset seizures for whom surgery is not recommended or for whom surgery has failed. Clinical documentation received does not support this request. Implanted vagal nerve stimulation is not indicated for cluster headaches.Therefore, we decided that the Plan does not have to pre-approve vagus nerve stimulation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve standard wheelchair elevating leg rests.
You asked the Plan to pre-approve elevating leg rests, pair (K0195). You say that you are unable to bear weight on your right leg and are unable to push a walker. The Plan denied your request. The Plan says criteria for elevating leg rests have not been met.
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 elevating leg rests, pair (K0195). Our physician reviewer found the enrollee has a history of shoulder pain and forearm pain and is unable to bear weight on the right leg and requires a wheelchair. The wheelchair and all accessories were approved with the exception of the elevating leg rests. Clinical documentation supports history of falls, bilateral lower extremity weakness, and loss of range of motion and pain in the knees. Based on available records, the enrollee does not meet criteria for coverage of elevating leg rests, pair (K0195). There is no documentation of the presence of a cast or brace which prevents 90 degree of flexion at the knee and/or significant edema of the bilateral lower extremities. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of elevating leg rests, pair (K0195) have not been met. Therefore, we decided that the Plan does not have to pre-approve a standard wheelchair and accessories.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve myocardial perfusion stress imaging for the enrollee. You asked the Plan to pre-approve the imaging. You say that this is medically necessary. The Plan denied your request. The Plan says there is no indication provided that the plan is for the enrollee to have this imaging. 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 the imaging. Our reviewer says that the requested imaging is not considered medically reasonable and necessary in this case. Our physician reviewer found based on the records, the enrollee has known coronary disease with stent placement less than 2 years ago and no documented anginal symptoms or abnormal cardiac physical exam findings on a most recent clinic visit 09/13/2019. In this circumstance, the documentation does not support the medical necessity for repeat nuclear stress testing. Current guidelines also do not support repeat nuclear stress testing in stable patients less than 2 years after coronary revascularization. Coverage criteria are not met since there are no documented covered indications for the procedure. 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 imaging have not been met. Therefore, we decided that the Plan does not have to pre-approve myocardial perfusion stress imaging for the enrollee
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea maxillary interim partial denture (code D5820).You asked the Plan to pre-approvethe maxillary interim partial denture. You say that the Plan offers extra coverage and up to $1,000coverage in dental services.The Plan denied your request. The Plan says this service is not covered by Medicare.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-approvea maxillary interim partial denture (code D5820).Your complaint about the Plan not covering this service is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan.Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forsurgical placement of implant body: endosteal implant (code D6010 x3), custom fabricated abutment -includes placement (code D6057 x3), and abutment supported porcelain/ceramic crown (code D6058 x3) to be provided by you.You asked the Plan to pay forthe endosteal implants, custom fabricated abutments, and abutment supported crowns. You say that these services are medically necessary.The Plandenied your request. The Plan says these services are not listed as covered services under the enrollee's contract under any normal circumstances.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceedsMedicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forsurgical placement of implant body: endosteal implant (code D6010 x3), custom fabricated abutment -includes placement (code D6057 x3), and abutment supported porcelain/ceramic crown (code D6058 x3) to be provided by you.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvepower wheelchair upgraded electronics, power seat elevation feature, and push handles to be provided by the provider .You asked the Plan to pre-approvepower wheelchair upgraded electronics, power seat elevation feature, and push handles. You say that the enrollee needs power wheelchair upgraded electronics, power seat elevation feature, and push handles.The Plan denied your request. The Plan says The power options come with their own switches and the push handles do not serve a medical purpose.The Plan must follow Medicare rules. Medicare rules state that options and accessories for wheelchairs are covered if the beneficiary has a wheelchair that meets Medicare coverage criteria and the option/accessory itself is medically necessary. The record shows upper limb strength and range of motion are adequate for the member to be able to control the power options using their own switches which are included in the allowance of these power options. The push handles at issue in this appeal does not servea 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-approvepower wheelchair upgraded electronics, power seat elevation feature, and push handles to be provided.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Optichamber MIS Diamond spacer bag/reservoir (A4627).You asked the Plan to pre-approve the spacer bag/reservoir. You say that you are on albertol but is not inhaling the inhaler correctly and the spacer would allow you to get all the medication without choking.The Plan denied your request. The Plan says this item is not considered DME and is therefore not covered by Medicare.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.While the spacer bag/reservoir 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-approveOptichamber MIS Diamond spacer bag/reservoir (A4627).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitoring system.
You asked the Plan to pre-approve a continuous glucose monitoring device. You say that your fingers hurt
from finger stick testing. The Plan denied your request. The Plan says you are not insulin injection three or
more times a day.
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 monitoring device have not been met. Therefore, we decided that the Plan
does not have to pre-approve a 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 you disagree with the determination and request review of the documentation supporting medical necessity of the requested equipment. The Plan denied your request. The Plan says the enrollee did not fail a 4 week trial of a basic lymphedema pump and therefore does not meet the criteria.
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: Supplemental Benefit
Decision: Unfavorable

We decided that thePlan does not have to pre-approvebone grafting and dental implants for the enrollee.You asked the Plan to pre-approvethese services. You say that the patient has failed other conventional endeavors to restore her masticatory function and thus requires this additional surgery.The Plan denied your request. The Plan says that this is not covered by the plan.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-approvebone grafting and dental implants for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvegingival irrigation (D4921) for the lower left and lower right quadrants, and retainer crowns (D6740) for teeth # 8 and 10.You asked the Plan to pre-approvethe gingival irrigation, and retainer crowns. You say that you have tooth ache pain. You also say that you need a crown or you will lose the tooth.The Plan denied your request. The Plan says the requested dental services are not listed as covered services.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, gingival irrigation, and retainer crowns are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approvegingival irrigation (D4921) for the lower left and lower right quadrants, and retainer crowns (D6740) for teeth # 8 and 10.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a second programmable medical device/pain pump for the enrollee.You asked the Plan to pre-approve the second device. You say that this is medically necessary.The Plan denied your request. The Plan says there is a medical contraindication for two pain pumps.The Plan must follow Medicare rules. Medicare rules say that an infusion pump is not covered when there is another programmable device, since cross talk between devices may inadvertently change the description. The records show that the enrollee already has a programmable gastric pacemaker device. Based on this information, we decided that Medicare rules for coverage of the second device have not been met.Therefore, we decided that the Plan does not have to pre-approve a second programmable medical device/pain pump for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve massage therapy.You asked the Plan to pre-approve massage therapy. You say that this will help reduce your pain.The Plan denied your request. The Plan says that this is not covered by Medicare.The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist.Therefore, we decided that the Plan does not have to pre-approve massage therapy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a stair glide.You asked the Plan to pre-approve a stair glide. You say that you had knee surgery and you have to avoid stairs because stairs inflame your knee.The Plan denied your request. The Plan says this item is not a covered benefit.The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they are not primarily medical in nature. While a stair lift 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 stair glide
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 you have difficulty going up and down steps and walking on uneven ground.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-approve dentures to be provided. You asked the Plan to pre-approve the dentures. You say that you were told that dentures would be included with your surgery. The Plan denied your request. The Plan says the service is not covered under your Plan.Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve dentures to be provided.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 2 heavy duty power wheelchair to be provided by out of network provider. You asked the Plan to pre-approve a Group 2 heavy duty power wheelchair from an out-of-network provider. You say that none of the in-network providers carry the  power wheelchair that you need.The Plan denied your request. The Plan says their in-network providers can provide a Medicare approved Group 2 heavy duty power wheelchair.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 network providers available who can provide the item at issue in this appeal. We found no exception that would require the Plan to pre-approve this item. Therefore, we decided that the Plan does not have to pre-approvea Group 2 heavy duty power wheelchair to be provided by out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to providea Flexitouch pneumatic compression device (E0652).You asked the Plan to providea pneumatic compression device. You say that the enrollee needs a pneumatic compression device for lymphedema.The Plan denied your request. The Plan says the enrollee does not have lymphedema above the lower extremitiesand there is no documentation of a failed trial with a basic PCD.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.The record shows there is no trunk/chest or abdominal swelling related to lymphedemaor chronic venous insufficiencyand the enrollee was non-compliant with visits. Therefore, we decided that the Plan does not have to providea Flexitouch pneumatic compression device (E0652).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvefoam dressings for trochanter and sacral wounds coded as A6211 and A6212.You asked the Plan to pre-approvethe foam dressings. You say that the enrollee would like to continue to use these foam dressing for her wounds.The Plan deniedyour request. The Plan says the documentation does not support that the wounds have moderate to heavy exudate.The Plan must follow Medicare rules. Medicare rules say that foam dressings for primary dressing are covered for stage III or IV wounds with moderate to heavy exudate.In this case, the physical exam notes from November 5, 2019 document a stage III pressure ulcer but there is no mention of the amount of exudate if any. The Plan contacted the provider who confirmed that there was scant exudate.Without documentation of at least moderate wound exudate, the coverage criteria for the foam dressings have not been met.Therefore, we decided that the Plan does not have to pre-approvefoam dressings for trochanter and sacral wounds coded as A6211 and A6212.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ataxia panel & spastic paraplegia complete panel.You asked the Plan to pre-approve ataxia panel & spastic paraplegia complete panel. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested services are not medically necessary.The Plan follows Medicare rules. Medicare rules say that ataxia and spastic paraplegia complete panels are only covered for certain 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 ataxia panel & spastic paraplegia complete panel. Our reviewer says that the documentation does not support that the requested services are medically reasonable or necessary. Our physician reviewer found the enrollee has had ataxia since her 40s. The enrollee's sister also has ataxia. The enrollee's sister underwent genetic testing, which was negative. There is no evidence to support that the requested testing is medically necessary or reasonable to diagnose, treat or otherwise manage the enrollee's health. Therefore, the enrollee does not meet criteria for the requested testing.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of ataxia panel & spastic paraplegia complete panel have not been met.Therefore, we decided that the Plan does not have to pre-approve ataxia panel & spastic paraplegia complete panel
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a radio frequency ablation (RFA) of the facet joint nerves.You asked the Plan to pre-approve the RFA procedure. You say that you feel that this should be approved to treat your pain.The Plan denied your request. The Plan says there is no evidence that prior RFA provided more than 50% pain relief for at least six months.The Plan must follow Medicare rules. Medicare rules say that RFAs are covered when two MBBs produce more than 80% pain relief. Repeat RFA requires 50% pain relief for six months.In this case, there is no evidence of a recent MBB. In addition, the prior RFA procedure was not documented to provide 50% pain relief for six months. As such, the Medicare rules for coverage of the RFA have not been met.Therefore, we decided that the Plan does not have to pre-approve a radiofrequency ablation (RFA) of the facet joint nerves.