Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a fixed partial denture sectioning (D9120).

You asked the Plan to pre-approve a fixed partial denture sectioning. You say that you need this service to repair bridge and alleviate pain. The Plan denied your request. The Plan says the service requested 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 a fixed partial denture sectioning (D9120).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CT, lumbar spine; without contrast material (CPT code
72131), for the enrollee.

You asked the Plan to pre-approve the CT scan. You say that due to the findings the enrollee will be
undergoing anterior cervical discectomy and fusion surgery and will need the CT cervical for surgical planning
and intra-operative guidance. The Plan denied your request. The Plan says the Medicare rules have not been
met.

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 the CT scan. Our physician reviewer
found the ordering physician has indicated that the enrollee has hyperreflexia and positive Hoffman's signs
indicative of cervical myelopathy. The ordering physician has indicated that a cervical CT scan is necessary for
operative planning. The enrollee also has a history of previous spinal fusion. The medical record does not
indicate that the back pain is due to lumbar disease, changed, or that the enrollee has had a trial of conservative
therapy. The documentation is insufficient to establish the medical reasonableness or necessity of the requested
service. The requested service cannot be recommended.

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 CT scan have not been met. Therefore, we decided that the Plan does not
have to pre-approve CT, lumbar spine; without contrast material (CPT code 72131), for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) for the enrollee.

You asked the Plan to pre-approve the device. You say that the basic pump was ruled because the existing pain levels preclude use of static pressure applied by basic pump. The Plan denied your request. The Plan says there is no documentation of chest, abdomen, or truncal edema, which is a requirement for E0652.

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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no trial and failure of conservative therapy. The edema does not extend to the chest, trunk, or abdomen. 

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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar sacral orthosis rendered on September 11, 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 there is no valid physician order.

The Plan must follow Medicare rules. The rules say that a supplier must have an order from the treating physician before dispensing any DMEPOS item to a beneficiary. 

We looked at the file and Medicare rules. There is no valid physician order for the DME. 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 lumbar sacral orthosis rendered on September 11, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility.

You asked the Plan to pre-approve SNF care. You say that you need therapy that only a SNF can provide. The Plan denied your request. The Plan says rules for SNF care have not been met.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you are a 63-year-old male who was admitted to an acute care hospital. In this case, there are identifiable skilled therapy service needs and identifiable skilled nursing service needs. However, you do not require skilled nursing or therapy services on a daily basis and do not meet severity of illness or intensity of service criteria for 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 care have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility.
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 the requested admission to an IRF is medically
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.

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
enrollee does not meet criteria for IRF admission. Our physician reviewer found the complexity of the
enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an
interdisciplinary approach to rehabilitation care. The enrollee's current medical condition does not require
intensive physician or nursing supervision in an IRF. The enrollee may benefit from additional physical and
occupational therapy, but the documentation does not reveal that this therapy must be only on an intensive level
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve retainer crowns (D6752 x 2) and Pontics (D6242 x 4).

You asked the Plan to pre-approve the bridge. You say that you are in constant pain and cannot chew any of your food. You say that you grind your teeth. You say that you need your front lower teeth to be extracted and you need a bridge. You also say that cannot afford to pay for the dental services. The Plan denied your request. The Plan says a bridge is excluded from coverage under the enrollee's dental coverage.

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 retainer crowns (D6752 x 2) and Pontics (D6242 x 4).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an acute inpatient hospital admission for a total knee
arthroplasty

You asked the Plan to pre-approve the acute inpatient hospital care. You say that an inpatient hospital
admission is medically necessary for the enrollee. The Plan denied your request. The Plan says an inpatient
hospital admission is not medically necessary for this procedure.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases,
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or
more.

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 acute inpatient hospital care. Our
reviewer says that an acute inpatient hospital admission is not medically necessary. Our physician reviewer
found that the enrollee is medically stable and has been provided medical clearance to undergo this elective
procedure. The planned procedure listed under CPT code 27447 is not listed on the CMS Inpatient Only List.
The arthroplasty procedure is currently approved as an ambulatory outpatient procedure. The review has
determined that the record does not show that the admitting physician reasonably expects that the patient's
necessary hospital care would span two midnights.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the
Plan does not have to pre-approve an acute inpatient hospital admission for a total knee arthroplasty.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre.

You asked the Plan to pre-approve a Freestyle Libre. You say that the services are necessary. The Plan denied
your request. The Plan says based on the documentation provided, 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. Based on this information, we decided that Medicare rules for
coverage of a Freestyle Libre have not been met. Therefore, we decided that the Plan does not have to preapprove
a Freestyle Libre.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied
your request. The Plan says the stay is 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
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found the complexity of your nursing, medical and rehabilitation needs do not require an
acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require
treatment by multiple therapies, including either physical therapy or occupational therapy, at an intensive
rehabilitation therapy program. There is not a reasonable expectation that you will be able to fully participate in
and benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility.
You continue to have a need for skilled therapy with ongoing safety concerns and a potential for functional
improvement however, the documentation does not support that you would meet criteria for admission to an
acute inpatient rehabilitation facility. There is no indication that you would require skilled rehabilitation in an
IRF, participating in rehab services fifteen (15) hours a week, under the supervision of a physician with at least
three (3) visits weekly to regain or maintain your functional status. You are ambulating up to ten (10) feet with
minimal assistance. You can receive services at a lower level of care. 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 IRF admission and
services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve outpatient surgery to be provided by the out-of-network provider.

You asked the Plan to pre-approve the outpatient surgery to be provided by the out-of-network provider. The Plan denied your request. The Plan says the requested service can be performed in-network.

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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve outpatient surgery to be provided by the out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve extraspinal manipulation services.

You asked the Plan to pre-approve these services. You say that you have bulging vertebrae. The Plan denied your request. The Plan says the services are not covered.

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation.

The records show that the service at issue is not manual manipulation of the spine. Extraspinal manipulation from a chiropractor is not covered by Medicare. Therefore, we decided that the Plan does not have to pre-approve extraspinal manipulation services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110).

You asked the Plan to pre-approve the complete maxillary denture. You say that you need this service to be approved for coverage. The Plan denied your request. The Plan says this service exceeds the maximum count allowed per period.

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, complete maxillary denture (D5110) is limited to one procedure every five plan years. The record shows that you received a complete maxillary denture (D5110) on June 18, 2019 and your complete maxillary denture (D5110) benefit has been exhausted. Therefore, we decided that the Plan does not have to pre-approve a complete maxillary denture (D5110).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a powered upper extremity range of motion assist device, elbow, wrist, hand, finger, single or double upright, includes microprocessor, sensors, all components and accessories, custom fabricated (L8702).

You asked the Plan to pre-approve this device. You say that this device is medically necessary for the enrollee. The Plan denied your request. The Plan says this device is not medically necessary as it has deluxe features that exceeds the enrollee's needs and replaces, rather than improves the function of her arm.

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 this device. Our reviewer says that the requested device is not considered medically reasonable and necessary in this case. Our physician reviewer found that at this time the requested robotic orthosis is not proven to be more beneficial for treatment of the patient's medical condition/function of hemiparesis after a stroke than any available standard therapy such as conventional treatments for post stroke hemiparesis therapy including constraint induced movement therapy, conventional muscle strengthening, and Botox for spasticity if needed. The requested device is not reasonable and necessary for the diagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member.

This device is not known to be effective, based on scientific evidence, professional standards and expert opinion, in improving health outcomes in stroke patients. It is not in widespread use based on scientific evidence. There is insufficient evidence in the literature that this orthosis will improve the long term outcome for this patient, improve hemiparetic arm function, or be safe for long term use. There is insufficient evidence in the literature that this device will increase participation in bimanual activities.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this device have not been met. Therefore, we decided that the Plan does not have to pre-approve a powered upper extremity range of motion assist device, elbow, wrist, hand, finger, single or double upright, includes microprocessor, sensors, all components and accessories, custom fabricated (L8702).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a deep brain stimulation consultation to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve the deep brain stimulation consultation. You say that you would like reconsideration because there are no providers in your network that offer the neurological treatment desired. The Plan denied your request. The Plan says the requested services are available in-network.

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 provider at issue in this case is not a network provider with the Plan. 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 deep brain stimulation consultation. Our reviewer says that the medical records provided for review did not indicate that there was a network deficiency of neurosurgeons who perform deep brain stimulation procedures. Our physician reviewer found there were no other unique or extenuating circumstances presented that would otherwise warrant a network coverage exception.

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 deep brain stimulation consultation have not been met.

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 the deep brain stimulation consultation. Therefore, we decided that the Plan does not have to pre-approve a deep brain stimulation consultation to be provided by an out of network (OON) provider.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pre-approve an echocardiography.

You asked the Plan to pre-approve an echocardiography, transthoracic, real-time with image documentation
(2D), includes M-mode recording, when performed, complete, with spectral Doppler echocardiography, and
with color flow Doppler echocardiography (93306). You say that the enrollee needs a follow up echo. The Plan
denied your request. The Plan says that the enrollee has not been evaluated since September 9, 2020, and there
is no recent documentation of any new or worsening symptoms.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item
or service, then that item or service will be covered when it is medically necessary.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve an echocardiography, transthoracic,
real-time with image documentation (2D), includes M-mode recording, when performed, complete, with
spectral Doppler echocardiography, and with color flow Doppler echocardiography (93306). Our reviewer says
that the requested service is considered medically reasonable and necessary in this case. Our physician
reviewer found an echo with a concomitant bubble study to rule out an intra-atrial cardiac communication is a
reasonable use of the echocardiogram technology for the specific indication of determining the etiology of the
prior right heart structural changes noted on the August 2020 study. This therefore meets the applicable CMS
LCD criteria.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of an echocardiography, transthoracic, real-time with image documentation (2D),
includes M-mode recording, when performed, complete, with spectral Doppler echocardiography, and with
color flow Doppler echocardiography (93306) have been met. Therefore, we decided that the Plan has to preapprove
an echocardiography.

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.