Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Veriflex spacer device.
You asked the Plan to pre-approve Veriflex spacer device. 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 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 Veriflex spacer device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has low back pain. The Veriflex spacer device is experimental. More research is needed to show safety and efficacy of the procedure. Open laminectomy is the gold standard surgery for spinal stenosis. Therefore, the enrollee does not meet criteria for the requested services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Veriflex spacer device have not been met. Therefore, we decided that the Plan does not have to pre-approve Veriflex spacer device.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve the pneumatic compression device (E0652).
You asked the Plan to pre-approve the pneumatic compression device. You say that you would like reconsideration because the member's unique condition failed to respond to conservative therapy or a basic device. The Plan denied your request. The Plan says that there is no recorded trial of a basic pump.
The Plan follows Medicare rules. Medicare rules say that a pneumatic compression device coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen when specific criteria 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 the pneumatic compression device. Our reviewer says that based on the trial and failure of the basic compression pump and as it would be inappropriate for a longer trial as the basic pump caused more swelling and pain, it is reasonable and medically necessary for the patient to utilize the requested pneumatic compression device. Our physician reviewer found it was reported that the member failed basic compression pump with a one-time trial with fluid building pressure in upper thighs and torso. 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 pneumatic compression device have been met. Therefore, we decided that the Plan has to pre-approve the pneumatic compression device (E0652).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Whole Mitochondrial Genome Sequencing testing.
You asked the Plan to pre-approve the Whole Mitochondrial Genome Sequencing testing.. You say that you would like reconsideration because this testing is medically necessary. The Plan denied your request. The Plan says the clinical value of Whole Mitochondrial Genome Sequencing in the setting of a possible mitochondrial disorder has not been demonstrated in the peer-reviewed literature.
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 Whole Mitochondrial Genome Sequencing testing. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found identifying the genetic cause of the member's mitochondrial disorder will not affect treatment. 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 Whole Mitochondrial Genome Sequencing testing. have not been met. Therefore, we decided that the Plan does not have to pre-approve Whole Mitochondrial Genome Sequencing testing.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a comprehensive oral evaluation and surgical extraction to be rendered by an oral surgeon.
You asked the Plan to pre-approve the comprehensive oral evaluation and surgical extraction. You say that the general dentist advised that you have these services rendered by an oral surgeon. The Plan denied your request. The Plan says dental services are only covered when they are performed by a participating general dentist. The Plan also says that dental services performed by an oral surgeon 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 covered when they are received by anyone other than a participating general dentist. Therefore, we decided that the Plan does not have to pre-approve a comprehensive oral evaluation and surgical extraction to be rendered by an oral surgeon.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network provider for a prosthetic.
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 available from network providers.
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 items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a referral to an out-of-network provider for a prosthetic.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Freestyle Libre 14 day sensor for the enrollee.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says there is a lack of medical necessity.

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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there was no documentation that the enrollee is insulin-treated with multiple daily injections or frequent adjustments to her regimen to obtain therapeutic status. The enrollee has not been using insulin multiple times (3 or more) a day. The treatment does not require frequent adjustment on the basis of testing results.

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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve the Freestyle Libre 14 day sensor for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve pain management injections (64624).

You asked the Plan to pre-approve pain management injections. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have 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 pain management injections. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this is an experimental/ investigational procedure that is the subject of ongoing clinical trials. Therefore, the request is considered medically unnecessary and unreasonable. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of pain management injections have not been met. Therefore, we decided that the Plan does not have to pre-approve pain management injections (64624).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a functional electrical stimulator (Bioness) (E0770).

You asked the Plan to pre-approve a Functional electrical stimulator (Bioness) (E0770). You say that the item is medically necessary. The Plan denied your request. The Plan says documentation submitted by your doctor does not prove that you have a spinal cord injury, nor have you participated in a training program with the functional electrical stimulator of at least 32 therapies.

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 a Functional electrical stimulator (Bioness) (E0770). Our reviewer says that the requested item is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation of you having a spinal cord injury, and you have not received 32 training sessions with the functional electrical stimulator.

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 Functional electrical stimulator (Bioness) (E0770) have not been met. Specifically, you do not have a spinal cord injury nor have you received 32 training sessions with functional electrical stimulator. This means the item is not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve a functional electrical stimulator (Bioness) (E0770).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve repairs and a custom seat for a power wheelchair (E2361, E2609, E2617, K0108, E1028, K0739, E0956).

You asked the Plan to pre-approve the repairs and custom seat. You say that these modifications are medically necessary. The Plan denied your request. The Plan says durable medical equipment is not eligible for coverage when provided in a SNF setting.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home. 

Records show that the wheelchair repairs and modifications are being requested for use in a SNF or hospital. Therefore, we decided that the Plan does not have to pre-approve repairs and a custom seat for a power wheelchair (E2361, E2609, E2617, K0108, E1028, K0739, E0956).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a consultation and surgical services to be provided by an out-of-network provider.
You asked the Plan to pre-approve a consultation and surgical services. You say that you have seen two surgeons and they refused to do the surgery. You say that this doctor is the best in the country and is the only one who can conduct the surgery. The Plan denied your request. The Plan says 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 requested provider in this case is not a network provider with the Plan. 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 these items/services. Therefore, we decided that the Plan does not have to pre-approve a consultation and surgical services to be provided by an out-of-network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vertiflex superion device placement surgery.

You asked the Plan to pre-approve Vertiflex superion device placement surgery. 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 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 Vertiflex superion device placement surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has chronic low back pain. The vertiflex spacer device remains experimental. More research is needed to show safety and efficacy of the device. Open laminectomy surgery remains the gold standard for lumbar decompression. Therefore, the enrollee does not meet criteria for the requested services. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Vertiflex superion device placement surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve Vertiflex superion device placement surgery.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve specialist services to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve specialist services. You say that you would like approval for this because this provider is closer to your home. The Plan denied your request. The Plan says there are in-network providers available for these 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 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 items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve specialist services to be provided by an out of network (OON) provider.
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 your condition. The Plan denied your request. The Plan says criteria for coverage of the pneumatic compression device has 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve endodontic therapy (D3310) for tooth #7.
You asked the Plan to pre-approve the endodontic therapy. You say that this service is medically necessary. The Plan denied your request. The Plan says this service is 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 endodontic therapy (D3310) for tooth #7.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve wheelchair options and accessories (K0040, E0971, E0978, E2366, E0973, E2377, E2313, and K0108).

You asked the Plan to pre-approve wheelchair options and accessories. You say that the wheelchair options and accessories are medically necessary. The Plan denied your request. The Plan says the wheelchair options and accessories are not covered.

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 wheelchair options and accessories. Our reviewer says that the wheelchair options and accessories are not medically necessary. Our physician reviewer found based on the medical records provided there is no documentation that the enrollee has a covered indication for the requested expandable controller (E2377), expandable controller harness (E2313), and Pride CTL Q Logic Controller per LCA A52504.

Medicare rules also say that a Column II code is included in the allowance for the corresponding Column I code when provided at the same time. When multiple codes are listed in column I, all the codes in column II relate to each code in column I. In this case K0842, approved by the Plan, is listed under Column I and K0040, E0971, E0978, and E2366 are listed under Column II. This means that payment for these wheelchair options or accessories are included in the approved K0842 code for the group 2 power wheelchair. Additionally, E1007 is listed under Column I and E0973 is listed under Column II. This means that payment for this item is included in the approved E1007 code.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of wheelchair options and accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve wheelchair options and accessories (K0040, E0971, E0978, E2366, E0973, E2377, E2313, and K0108).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex Superion spacer.

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 a history of back pain and lumbar spinal stenosis. The requested Superion spacer is considered experimental in nature, as more research is needed to show safety and efficacy. Open laminectomy surgery is the gold standard procedure for spinal spinal stenosis. The Superion spacer is 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 a Vertiflex Superion spacer.
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 this is medically necessary. The Plan denied your request. The Plan says the enrollee has not had a change in function that needs daily skilled services on an inpatient basis.

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 the enrollee does not have any parental medication, complex wound care, or nutrition given via a feeding tube. He is medically stable without any acute exacerbations of chronic medical problems. Although further rehabilitation services would be appropriate to improve function, as a practical matter, the intermittent skilled services can be provided at a lower level of care than a skilled nursing facility.

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.