Persius/hicric huggingface dataset:
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 this service is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the criteria for a pneumatic compression device have not been met.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a mattress.
You asked the Plan to pre-approve a mattress. You say that this item is necessary for your condition. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a mattress.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve GO Foot Drop System.
You asked the Plan to pre-approve the requested device. The Plan denied your request. The Plan says this
treatment is considered experimental for your diagnosis.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We looked at the file, and Medicare rules. In this case, there are insufficient medical records to show that the
requested device is reasonable and necessary. There were no medical records provided to show that the
standard of care for your condition has been tried and failed. Based on this information, we decided that
Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to preapprove
GO Foot Drop System.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the doppler exams provided on August 6, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the OON services. The Plan denied your request. The Plan says the enrollee's plan requires utilization of network providers, and authorization for certain services.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the doppler exams provided on August 6, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve a BiPAP device (E0470) and a heated humidifier (E0562).
You asked the Plan to pre-approve a BiPAP device and a heated humidifier. You say that the requested items are medically necessary for the enrollee. The Plan denied your request. The Plan says that there is no documentation that a CPAP device was ineffective.
The Plan must follow Medicare rules. Medicare rules say that a BiPAP device is covered for the treatment of obstructive sleep apnea (OSA) if certain criteria, listed in the "Medicare rules" section of this letter, are 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 a BiPAP device and a heated humidifier. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee has OSA, and a sleep study with PAP titration on May 23, 2018, demonstrated hypoventilation, and failure of CPAP and standard BiPAP to correct the disordered breathing, hypoventilation, and hypoxemia. Intelligent volume assured pressure support (iVAPS) mode with specific settings was found to be most effective. This was recommended, along with tracking of the residual AHI. The records do not show any follow-up after the initial prescription for BiPAP/iVAPs. BiPAP with iVAPS mode, at the settings recommended in the 2018 sleep study, is medically necessary for the enrollee. Follow-up within 3 months is needed to assess benefit and compliance. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a BiPAP device and a heated humidifier have been met. Therefore, we decided that the Plan has to pre-approve a BiPAP device (E0470) and a heated humidifier (E0562).
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the acute IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that you feel you would benefit from going to an IRF. The Plan denied your request. The Plan says it is unlikely that you are able to tolerate a minimum of three hours of therapy, five days a week.

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. Our reviewer found that 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. Our physician reviewer also found that 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 the acute IRF admission and services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the motion fluoroscopic evaluation of swallowing function
by cine or video recording and the x-ray services provided on September 15, 2020, by an OON provider.

You asked the Plan to pay for the motion fluoroscopic evaluation of swallowing function by cine or video
recording and the x-ray services. You say that you would like the plan to reconsider their denial. The Plan
denied your request. The Plan says the services rendered are not a covered benefit.

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 pay for 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 had network providers
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. No medical records were provided to support medical necessity of the services rendered.
We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that
the Plan does not have to pay for the motion fluoroscopic evaluation of swallowing function by cine or video
recording and the x-ray services provided on September 15, 2020, by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an interim complete upper denture (D5810).
You asked the Plan to pre-approve the dental service. You say that you need the dentures. You also say that it makes her uncomfortable. The Plan denied your request. The Plan says interim complete upper denture is not listed as a covered service. The Plan also says that any service not listed are not covered.
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 an interim complete upper denture (D5810).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve myocardial perfusion imaging (MPI).

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 medically necessary.

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 these services. Our reviewer says that
the services are not medically necessary. Our physician reviewer found the enrollee has no cardiac symptoms
or complaints and a history of mild non-rheumatic valvular heart disease. His physical exam and
electrocardiogram (EKG) are normal. He has no history of known ischemic cardiovascular disease, peripheral
vascular disease, prior myocardial infarction, or prior revascularization procedures. The criteria for coverage
are not met and the MPI is therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve myocardial perfusion imaging (MPI).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician's services to be provided by the out-of-network provider.

You asked the Plan to pre-approve the physician's services to be provided by the out-of-network provider. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the Plan.

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 physician's services to be provided by the out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the acute IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that the enrollee currently meets the full IRF criteria. The
Plan denied your request. The Plan says the enrollee does not appear to require any specialized therapeutic
skills or equipment for therapy needs. The Plan also says that the enrollee's appropriate therapy needs are not
precluded in an alternate level of care.

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 the enrollee's nursing, medical and rehabilitation needs does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer
found that the enrollee does 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. Our physician reviewer also
found that there is not a reasonable expectation that this enrollee 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 the acute IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pontic (D6240) for tooth #15 and retainers (D6545)
for teeth #'s 14 and 16.

You asked the Plan to pre-approve the pontic and retainers. You say that you do not need dentures. The Plan
denied your request. The Plan says the notes do not indicate a medical reason that you are not able to use a
denture.

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 pontic and
retainers 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 pontic and retainers. Our reviewer
says that there was no documentation to indicate that a removable appliance is contraindicated to replace the
missing posterior tooth #15. Our physician reviewer found there is no indication that a removable appliance
cannot be used to replace the missing tooth. Our reviewer also found that according to the Plan, if there is a
documented reason for the inability to use a removable appliance a fixed appliance would be considered for
coverage.

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 pontic and retainers have not been met. Therefore, we decided that the Plan
does not have to pre-approve a pontic (D6240) for tooth #15 and retainers (D6545) for teeth #'s 14 and 16.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiology services to be provided by an out of network provider.

You asked the Plan to pre-approve shoulder x-ray, mammogram, and bone density scan. You say that you want to go to this facility as it is only 5 miles from your home. The Plan denied your request. The Plan says the records do not show why you cannot get these services from an in-network provider.

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 radiology services to be provided by an out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sacroiliac joint injections (27096).

You asked the Plan to pre-approve sacroiliac joint injections. You say that the injections are medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.

The Plan must follow Medicare rules. Medicare rules say that 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 sacroiliac joint injections. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found a previous injection only provided 30% pain relief. This is not sufficient pain relief to demonstrate effectiveness, and therefore recommend additional injections.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of sacroiliac joint injections have not been met. Therefore, we decided that the Plan does not have to pre-approve sacroiliac joint injections (27096).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for an inpatient hospital stay for a total left reverse shoulder arthroplasty with tenodesis for the enrollee.

You asked the Plan to pay for acute inpatient hospital care. You say that this is medically necessary. The Plan denied your request. The Plan says this procedure is currently approved as an ambulatory 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 pay for acute inpatient hospital care. Our reviewer says that the request for inpatient hospital stay for total left reverse shoulder arthroplasty with tenodesis is not medically necessary. Our physician reviewer found this procedure is literature supported to be an outpatient procedure. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the request for inpatient hospital stay for total left reverse shoulder arthroplasty with tenodesis is not medically reasonable or 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 acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for an inpatient hospital stay for a total left reverse shoulder arthroplasty with tenodesis for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two core buildups, including any pins when required (D2950 x2).

You asked the Plan to pre-approve the core buildups. You say that you would like this service to be approved for coverage. The Plan denied your request. The Plan says this service is not covered under your benefit 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-approve two core buildups, including any pins when required (D2950 x2).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an oxygen concentrator (E1390) and a portable oxygen concentrator (E1392) from a new DME provider.

You asked the Plan to pre-approve an oxygen concentrator and a portable oxygen concentrator. You say that the requested items are a necessity for the enrollee. The Plan denied your request. The Plan says the request is for a duplication of services because the enrollee has an active authorization on file for oxygen services from another DME provider.

The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. 

The file shows that the enrollee has a current authorization to use another DME provider for oxygen services. The Plan has verified with the enrollee that the currently authorized provider is acceptable. Therefore, we decided that the Plan does not have to pre-approve an oxygen concentrator (E1390) and a portable oxygen concentrator (E1392) from a new DME provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Fasenra pen for the enrollee.

You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says drug coverage is limited to Medicare Part B covered drugs.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Fasenra pen for the enrollee.