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

We decided that the Plan does not have to pre-approve transcutaneous electrical nerve stimulation (TENS) 
therapy. 
 
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 criteria for coverage are not met. 
 
The rules say that TENS therapy for chronic low back pain is covered when the beneficiary is enrolled in an 
approved clinical study.  
 
We looked at the file and Medicare rules. The file shows that the enrollee is not in an approved clinical study 
for these services. 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 transcutaneous electrical 
nerve stimulation (TENS) therapy.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acupuncture services (99499) to be provided by an outof-
network provider.
You asked the Plan to pre-approve the acupuncture services. You say that the services are medically necessary.
The Plan denied your request. The Plan says the services are not emergent or pre-authorized. There are network
providers available.
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 acupuncture services (99499) to be provided by an out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ilumya (J3245). You asked the Plan to pre-approve Ilumya. You say that Ilumya is medically necessary. The Plan denied your request. The Plan says a trial of Remicade, or Inflectra, and Stelara is required before alternatives can be considered.
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 Ilumya. Our reviewer says that Ilumya is not medically necessary. Our physician reviewer found the record shows no trial of the plan preferred drugs or any reason they would be unsafe or ineffective for the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Ilumya have not been met. Therefore, we decided that the Plan does not have to pre-approve Ilumya (J3245).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a LifeAlert system.
You asked the Plan to pre-approve the system. You say that this is medically necessary. 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. Therefore, we decided that the Plan does not have to pre-approve a LifeAlert system.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network provider at the in-network level.
You asked the Plan to pre-approve these services. You say that the network providers do not have the same credentials. The Plan denied your request. The Plan says the services are available from network providers at the in-network level.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 40% of the total cost for out-of-network Medicare-covered physician/practitioner services.
You are requesting services from an out-of-network provider. If you choose to see this provider, you will be asked to pay 40% of the total cost for these services. These services fall within the out-of-network Medicare-covered physician/practitioner services benefit category. This means that you will be asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. You are able to see the out-of-network provider at the out-of-network cost sharing, per your contract with the Plan. Therefore, we decided that the Plan does not have to pre-approve a referral to an out-of-network provider at the in-network level.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 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 the record indicates that the enrollee is improving but will require long term 
intravenous antibiotics. The record indicates that the plan has identified in network facilities at a lower level of 
care that are able to manage the enrollee's needs. The enrollee continues to receive acute care services, and 
these have not been denied. The medical record does not indicate that the enrollee requires services that the 
enrollee is not currently receiving but that would be available at the LTACH facility. The elements of the 
coverage rules are not satisfied. 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve comprehensive periodontal evaluation - new or established patient (CPT code D0180), bone replacement graft - retained natural tooth - first site in quadrant (CPT code D4263) and gingival flap procedure, including root planing - one to three contiguous teeth or tooth bounded spaces per quadrant (CPT code D4241).
You asked the Plan to pre-approve the dental services. You say that you are suffering due to your condition and these services are important to keep your dental health and help you eat. The Plan denied your request. The Plan says the services are not a covered benefit under the plan.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. The services are not listed in your EOC as a covered benefit; therefore, the services are not covered. Therefore, we decided that the Plan does not have to pre-approve comprehensive periodontal evaluation - new or established patient (CPT code D0180), bone replacement graft - retained natural tooth - first site in quadrant (CPT code D4263) and gingival flap procedure, including root planing - one to three contiguous teeth or tooth bounded spaces per quadrant (CPT code D4241).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
You asked the Plan to pre-approve SNF services. You say that the enrollee's family would like her to be admitted to a SNF. The Plan denied your request. The Plan says that this patient has been and continues to require a custodial level of care. 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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that Plan does not have to pay for medical services provided to the enrollee on January 21, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says there were no medical records submitted with this claim to support the services billed. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes and medical record documentation to support the services billed. In this case, the Plan shows you were asked repeatedly to submit medical records associated with this claim however, those requests were not responded to. Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for medical services provided to the enrollee on January 21, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional headgear for a positive airway pressure device (device to aid breathing) every six months.
You asked the Plan to pre-approve the additional headgear. You say that this is not a viable timeframe for you because the device at this time has been stretched out to be very bad performing. The Plan denied your request. The Plan says the Medicare rules have not been met.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the additional headgear have not been met. You are requesting additional headgear for a positive airway pressure device (device to aid breathing) every six months. This is in addition to your benefit of one headgear every six months. The request is not approved because it is for a quantity of supplies greater than the usual maximum amounts and is therefore, not reasonable and necessary. The rules states that the following represents the usual maximum amount of accessories expected to be reasonable and necessary: CPAP headgear is approved at a rate of one every 6 months-CPT code A7035. Quantities of supplies greater than those described in the policy as the usual maximum amounts will be denied as not reasonable and necessary. Therefore, we decided that the Plan does not have to pre-approve additional headgear for a positive airway pressure device (device to aid breathing) every six months.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission and services. 
 
You asked the Plan to pre-approve SNF services. You say that the services are necessary to prevent falls and 
injury. The Plan denied your request. The Plan says you do not require daily skilled therapy 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 services. Our physician reviewer 
found that you do not have documented skilled nursing needs. You do not have documented skilled therapy 
needs.  Daily skilled services are not shown to be required to establish a maintenance program or to prevent 
deterioration of your condition. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a skilled nursing facility (SNF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

e decided that the Plan does not have to pre-approve a flex-walk foot system (prosthetic code L5981).
You asked the Plan to pre-approve flex-walk foot. You say that your physician has signed a detailed description saying that you are a K3 patient. The Plan denied your request. The Plan says the denial of authorization for this prosthetic component is correct, because you are currently a K2 ambulator so this K3 component is not indicated.
The Plan follows Medicare rules. Medicare rules state that a flex-walk foot system may be covered for K3 ambulators. 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 flex-walk foot. Our reviewer says that you do not meet the Medicare criteria for this flex-walk foot system. Our physician reviewer found you require and use a power wheelchair for mobility. This is not consistent with K3 ambulatory status and the requested flex-walk foot system. Records do not document that you have the ability to traverse most environmental barriers and may have vocational, therapeutic, or exercise activity that demands prosthetic utilization beyond simple locomotion. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of flex-walk foot have not been met. Therefore, we decided that the Plan does not have to pre-approve a flex-walk foot system (prosthetic code L5981).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve osteogenesis (bone growth) stimulator (CPT code 
E0748). 
 
You asked the Plan to pre-approve the stimulator. You say that it is necessary for you to have the bone 
stimulator put on your back for you to be able to walk and fuse your bones. The Plan denied your request. The 
Plan says you have only had a single-level fusion at the L4-L5 vertebrae. 
 
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 stimulator. Our physician reviewer 
found the review indicates that per the Medicare guidelines, an osteogenesis stimulator may be covered for 
members who had a failed spinal fusion at least nine months ago, a multilevel spinal fusion surgery including at 
least three or more vertebrae (such as L3-L5, L4-S1, etc.), or a spinal fusion surgery where there is a history of 
previously failed spinal fusion at the same site. 

Based on the information received, you only had a single-level fusion at the L4-L5 vertebrae. The review has 
determined that the medical records provided do not meet the requirements listed in the LCD for Medicare 
coverage. 
 
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 stimulator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve osteogenesis (bone growth) stimulator (CPT code E0748).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a partial hospitalization program (PHP).

You asked the Plan to pre-approve the PHP admission. You say that you have a previous history of psychiatric 
and psychological treatment from 2 years ago, but it was interrupted. You say that you are willing to participate 
in treatment voluntarily. The Plan denied your request. The Plan says you do not meet the criteria for admission 
to the program. 
 
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 PHP admission. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the provided documentation for the dates in question does not show any 
dangerousness to self or others tolerating treatment and not showing any perceptual disturbance or psychosis. 
The reviewer found that based on the American Association of Community Psychiatrists Level of Care 
Utilization System, the requested level of care 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 the PHP admission have not been met. Specifically, the record does not show 
any dangerousness to self or others. Therefore, we decided that the Plan does not have to pre-approve 
admission to a partial hospitalization program (PHP).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a car trailer.
You asked the Plan to pre-approve a car trailer. You say that you are requesting a trailer that can have your scooter loaded for you to use to keep weight off your right foot. The Plan denied your request. The Plan says this item is not covered.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a car trailer have not been met. The requested item is not a covered benefit because it is not considered DME. Therefore, we decided that the Plan does not have to pre-approve a car trailer.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided by an out-of-network provider from May 21, 2020, through February 25, 2021.
You asked the Plan to pay for the laboratory services. You say that the tests were requested by the doctor during pain management treatment to monitor the intake of prescribed medication and control the compliance of the patient. You say that you do not perform any services except testing based on the doctor's order and the denial should be reconsidered. The Plan denied your request. The Plan says in-network providers are available.
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. 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 laboratory services provided by an out-of-network
provider from May 21, 2020, through February 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CPAP machine (CPT code E0601).
You asked the Plan to pre-approve the CPAP machine. You say that you have been affected by the recall on the CPAP. The Plan denied your request. The Plan says the reasonable useful lifetime of at least five (5) years has not been met.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the CPAP machine have not been met. Review of the records show that your current equipment was issued less than five (5) years ago. Therefore, we decided that the Plan does not have to pre-approve CPAP machine (CPT code E0601).
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve a spinal cord stimulator trial (63650, L8680).
You asked the Plan to pre-approve a spinal cord stimulator trial. You say that this is medically necessary. The
Plan denied your request. The Plan says that this is not covered for the enrollee's condition.
The Plan follows Medicare rules. Medicare rules say that Spinal cord stimulators may be covered as therapy for
relief of chronic intractable pain, provided that the conditions listed in the NCD 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 spinal cord stimulator trial. Our
reviewer says that the requirements for coverage have been met. Our physician reviewer found the
documentation supports that the spinal cord stimulator is to be used on an enrollee with chronic intractable
pain, and that other treatment modalities have not proven satisfactory or are judged to be unsuitable for the
enrollee in this case. Careful screening, evaluation, and diagnosis, including psychological evaluation, have
been documented. At this time, it is medically and reasonable to trial a temporary implanted electrode.
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 spinal cord stimulator trial have been met. Therefore, we decided that the Plan
has to pre-approve a spinal cord stimulator trial (63650, L8680).
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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve non-emergency ambulance transport for the enrollee.
You asked the Plan to pre-approve the transport. You say that this is medically necessary. The Plan denied your request. The Plan says transportation is not covered to a physician's office or a physician-directed clinic.
The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when they meet certain origin and destination requirements. A doctor's office is not a covered destination. The services you have asked the Plan to pre-approve are ambulance transport services to a doctor's office. Therefore, we decided that the Plan does not have to pre-approve non-emergency ambulance transport for the enrollee.