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

We decided that the Plan does not have to pre-approve the UPWalker upright walker.
You asked the Plan to pre-approve the upright walker. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee has been approved for a standard walker coded as E0147. The unspecified code E1399 is correctly denied as this is not a covered item.
The Plan must follow Medicare rules. Medicare rules say that no payment can be made to suppliers not enrolled in the Medicare program. Medicare covers walkers as described in the Medicare rules section. In this case, the specific type of walker requested is offered by a manufacturer that is not enrolled in the Medicare program. There are covered walkers available from Medicare enrolled suppliers. As this supplier is not enrolled, the product being offered cannot be paid by Medicare. Therefore, we decided that the Plan does not have to pre-approve the UPWalker upright walker.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide additional transportation.
You asked the Plan to provide additional transportation. You say that the enrollee cannot drive and needs to get to appointments. The Plan denied your request. The Plan says the enrollee has exhausted the covered benefit of 6 trips.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 6 one-way trips each year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to provide additional transportation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide a therapeutic continuous glucose monitoring system.
You asked the Plan to provide a therapeutic continuous glucose monitoring system. You say that the enrollee needs a CGM. The Plan denied your request. The Plan says criteria is not met for a CGM.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of a therapeutic continuous glucose monitoring system have not been
met. Therefore, we decided that the Plan does not have to provide a therapeutic continuous glucose monitoring system.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says the services can be safely received in other settings.
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 does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for a heart attack and had coronary artery bypass grafting. Medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical
therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 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 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 admission to an inpatient rehabilitation facility (IRF).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve five (5) additional skilled nursing visits.
You asked the Plan to pre-approve additional skilled nursing visits. You say that you need a skilled nurse to come in and treat your wounds as you cannot do this by yourself. The Plan denied your request. The Plan says the wound is not complex, there are no signs of infection, it has not been debrided, and the wound care does not require a skilled nurse.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.
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 additional skilled nursing visits. Our physician reviewer found the records do show that skilled nursing services are required to effectively provide treatment, care, and/or services in order to improve your condition, or to establish/perform a maintenance program to maintain your condition and/or prevent deterioration. Your healing and not complex and the patient had instruction on disease process, pain management, signs/symptoms of infection, nutrition and wound care/dressing and patient verbalizes understanding. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of additional skilled nursing visits have not been met. Therefore, we decided that the Plan does not have to pre-approve five (5) additional skilled nursing visits.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prednisone Tab.
You asked the Plan to pre-approve Prednisone Tab. You say that you want the enrollee to be treated with this drug. The Plan denied your request. The Plan says this drug is not covered under the enrollee's Medicare Part B drug benefit.
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 Prednisone Tab.
Benefits for Prednisone Tab may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea continuous glucose monitor (CGM).You asked the Planto pre-approvethe CGM. You say that this is medically necessary.The Plandenied your request. The Plansaysthis is not covered as the enrollee does not require insulin injections.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 dailyinjections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of the CGM have not been met.Therefore, we decided that the Plandoes not haveto pre-approvea continuous glucose monitor (CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the sacroiliac joint injection (27096) provided on November 6, 2020.You asked the Plan to pay for the sacroiliac joint injection. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says the billed procedure code 27096 is not included on Addendum AA Final ASC Covered Surgical Procedures for Calendar Year 2020 and is not eligible for payment.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.We find that CPT code 27096 is not supported in the record. Specifically, CPT code 27096 is not included in CMS' list of ASC covered surgical procedures for calendar year 2020. As such, CPT code 27096 does not meet criteria for billing or reimbursement consideration. Based on this information, we decided that Medicare rules for coverage of the sacroiliac joint injection have not been met.Therefore, we decided that the Plan does not have to pay for the sacroiliac joint injection (27096) provided on November 6, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea Visco-3 injection for the enrollee.You asked the Planto pre-approvethe injection. You say that this is medically necessary.The Plandenied your request. The Plansaysthe enrollee has not tried and failed the preferred step therapy drugs. 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 the injection. Our reviewer says that the requested drug is not medically reasonable or necessary.Our physician reviewer found the enrollee has not trialed one viscosupplemental treatment such as Orthovisc and Monovisc. Step therapy, as outlined by the plan, requires that one of these be trialed first. The documentation does not outline contraindications or reasons these medications were not considered. Without the support of the documentation, Visco-3 is not approved as step criteria have not been met.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 injection have not been met.Therefore, we decided that the Plandoes not haveto pre-approvea Visco-3 injection for the enrollee.
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 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 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 reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where they are currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.
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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Praluent.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says self-administered drugs are not covered.
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 Praluent.
Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: 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 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 health plan's denial should be upheld. The enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen (15) hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 2 multiple power option power wheelchair (K0842).

You asked the Plan to pre-approve power wheelchair power tilt and recline seating system and power leg elevation feature. You say that the enrollee is incapable of pressure relieving sufficiently or repositioning. The Plan denied your request. The Plan says the office notes do not show evidence of severe lower extremity edema therefore the power elevating leg rests are not supported, and there is no evidence of current or past history of pressure ulcers therefore the power tilt and recline are not supported.

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.

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 power tilt and recline seating system and power leg elevation feature. Our reviewer says that the options are not medically necessary. Our physician reviewer found based on the medical records provided there is no documentation that the enrollee meets criteria for elevating leg rests and tilt/recline system. The provided medical records repeatedly document no edema and full range of motion of the extremities with no documentation of pressures ulcers or need for urinary catheterization.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of power tilt and recline seating system and power leg elevation feature have not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 2 multiple power option power wheelchair (K0842).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the computed tomographic angiography (CTA) of the heart (75574).

You asked the Plan to pre-approve the CTA of the heart. You say that this service is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the requested imaging service is not medically reasonable and necessary as there is no documentation of known cardiac disease, no abnormal stress test, and no concern for congenital heart disease

The Plan follows Medicare rules. Medicare rules say that the requested imaging service is subject to the indications listed 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 the CTA of the heart. Our reviewer says that the requested imaging service is not medically reasonable and necessary. Our physician reviewer found although the patient has coronary calcification seen on a low dose chest computed tomography scan, she is active and has no prior history, or symptoms of cardiovascular disease. She is being treated with guideline directed therapy for cardiovascular risk factor reduction. She had a stress test in 2018 which was negative for ischemia and a recent echocardiogram which showed normal left ventricular function. She has had no interval cardiac events or symptoms of cardiac disease noted since the prior stress test. In the absence of symptoms suggestive of coronary artery disease (chest pain or anginal equivalent syndrome), a lack of prior history of cardiovascular disease or prior revascularization procedures, with no suspicion of congenital coronary anomalies and no recent equivocal stress test, she does not meet the applicable covered indications and criteria for the CTA of the heart.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CTA of the heart have not been met. Therefore, we decided that the Plan does not have to pre-approve the computed tomographic angiography (CTA) of the heart (75574).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a privacy flap and electronic connection for a power wheelchair (PWC).

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.

The requested privacy flap does not serve a purpose that is primarily medical in nature. The requested
electronic connection is not needed, as the approved power options come with their own switches. Therefore, we decided that the Plan does not have to pre-approve a privacy flap and electronic connection for a power wheelchair (PWC).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. 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. 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 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 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 skilled nursing facility (SNF) care.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have pre-approve additional non-emergency ambulance, 180 one-way trips.
You asked the Plan pre-approve the transportation services. You say that the enrollee is being treated for a medical condition. You say that the enrollee requires daily transportation to and from the clinic for medication management for 90 days. The Plan denied your request. The Plan says the enrollee is not confined to a bed. The Plan says that this is a requirement for non-emergency ambulance services. The Plan also says that the non-emergency transportation is not medically necessary.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 60 one-way trips each calendar year trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. The record shows that the Plan approved 60 one-way trips that have been used. Therefore, we decided that the Plan does not have pre-approve additional non-emergency ambulance, 180 one-way trips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.
You asked the Plan to pre-approve a shower chair. You say that you need the item, so you do not lose balance. The Plan denied your request. The Plan says a bath/shower chair is not for a medical problem and makes it easier to take a bath or shower. Neither Medicare nor your health plan covers this
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair 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 shower chair.