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

 
We decided that the Plan has to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a CGM. You say that you would like the Plan to reconsider their denial. The 
Plan denied your request. The Plan says that you do not meet criteria. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, it is the plan's responsibility to show that its decision to deny 
coverage is correct. The plan did not provide sufficient medical records in order to determine if the enrollee 
meets Medicare criteria for the requested continuous glucose monitor. The enrollee states they check their 
blood glucose levels multiple times per day and they are on insulin. The Plan provided no documentation 
verifying that the enrollee does not meet Medicare criteria for a continuous glucose monitor. Therefore, we 
decided that the Plan has to pre-approve a continuous glucose monitor (CGM).  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Carafate. 
 
You asked the Plan to pre-approve Carafate. You say that you would like the Plan to reconsider their denial. 
The Plan denied your request. The Plan says Carafate is not covered under your Medicare Part B 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 Carafate.  
 
Benefits for Carafate 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that inpatient skilled nursing facility care is medically 
necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for 
coverage of inpatient skilled nursing facility 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 care. Our reviewer says that 
inpatient skilled nursing facility care is not medically necessary. Our physician reviewer found that the enrollee 
was admitted to the skilled nursing facility on April 3, 2021 to continue care and rehabilitation after a 
hospitalization with pneumonitis, respiratory failure, and sepsis. The enrollee had continued muscle weakness. 
His feeding is being administered via a percutaneous endoscopic gastrostomy tube. The enrollee may benefit 
from continued skilled therapy services; however, the documentation provided does not support that those 
services are medically necessary on a daily basis. Additionally, as a practical matter, the enrollee does not 
require the necessary services on 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 inpatient skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay the in network rate for the periapical x-rays (D0230) and the 
crown (D2740) provided on October 28, 2020. 
 
You asked the Plan to pay the in network rate for the dental services. You say that you called the Plan before 
you went the dentist. You say that you wanted to make sure that the dentist was in network. You say that you 
knew you needed a lot of work done so you needed to find an in network dentist. You also say that you were 
told that this dentist was in network. The Plan denied your request. The Plan says 1 periapical x-ray per 
calendar year and 2 crowns per calendar year. The Plan says that the frequency limitations for these services 
have been exceeded. The Plan says that when you contacted them to verify if the provider's office was in 
network. The Plan says you were advised that the provider you inquired about was in network, but this was a 
different provider than the one in this case. 
 
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 and the services are listed as covered, 
the frequency limit for these services have been exceeded. The record shows that the Plan paid for the 
periapical x-ray that you received on June 16, 2020. The record shows that the Plan paid for 2 crowns that you 
received on September 11, 2020. Therefore, we decided that the Plan does not have to pay the in network rate 
for the periapical x-rays (D0230) and the crown (D2740) provided on October 28, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve posterior cervical spine fusion using the Providence DTRAX cervical cage system.

You asked the Plan to pre-approve DTRAX surgery. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because the DTRAX system remains experimental, and the enrollee may have a contraindication to this procedure.

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 DTRAX surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the DTRAX cervical cage system is experimental in the posterior cervical spine. More research is needed to show the safety and efficacy of the posterior cage system in the cervical spine. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of DTRAX surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve posterior cervical spine fusion using the Providence DTRAX cervical cage system.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.

You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that daily physical and occupation therapy is not medically necessary to establish a maintenance program, to prevent deterioration, or to preserve current physical capabilities.
 
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 your 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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the lumbar-sacral orthosis (L0637) 
provided October 21, 2020. 
 
You asked the Plan to waive the coinsurance for the lumbar-sacral orthosis. You say that because the orthosis 
was not helpful, you would like the coinsurance waived. The Plan denied your request. The Plan says the 
coinsurance has processed correctly and no reimbursement is due. 
 
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 a 20% 
coinsurance for durable medical equipment.  
 
You have been asked to pay a total cost share of $272.24 for the lumbar-sacral orthosis ($1371.22 allowed 
amount x 20% coinsurance). This service falls within the durable medical equipment benefit category. This 
means that you have been 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. Therefore, we decided that 
the Plan does not have to waive the coinsurance for the lumbar-sacral orthosis (L0637) provided October 21, 
2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on September 10, 2020. 
 
You asked the Plan to pay for the laboratory services. The Plan denied your request. 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 Plan says that the Plan has also determined that these services are not urgent or 
emergent, nor were they approved in advance. 
 
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 did not pre-approve the 
laboratory services. 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 laboratory services provided on September 10, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation.

You asked the Plan to pre-approve radiofrequency ablation. You say that this service is medically necessary. The Plan denied your request. The Plan says the criteria for radiofrequency ablation has not been met.

The Plan follows Medicare rules. Medicare rules say that there must be a minimum of 50% improvement in pain for at least six months following the first radiofrequency ablation procedure.

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 radiofrequency ablation. Our reviewer says that the requested service is not medically reasonable and necessary. Our physician reviewer found there was not enough pain reduction documented with previous injections for the coverage criteria for radiofrequency ablation to be approved.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of radiofrequency ablation have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says medical studies have not proven that this procedure is helpful for treatment of the health 
problem. 
 
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 items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no specific indication provided to support the request for bone marrow aspirate for the 
approved surgery. There is no compelling rationale presented or extenuating circumstances noted to support the 
medical necessity of bone marrow aspiration in conjunction with the lumbar surgery performed. There is a lack 
of large volume, long-term peer-reviewed outcome studies to support the use of bone marrow aspirate for this 
enrollee's medical condition as discussed above. Therefore, the request for bone marrow aspirate is not 
medically reasonable and necessary for the approved lumbar fusion. 
 
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 bone marrow aspirate.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient hospital services for a total shoulder arthroplasty procedure.

You asked the Plan to pre-approve inpatient services. The Plan denied your request. The Plan says there is no documentation to support the enrollee will require a greater than 2 midnight stay.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve inpatient services. Our physician reviewer found that the enrollee has been approved for an elective reverse total shoulder arthroplasty. The enrollee is medically stable. The procedure is not listed on the Centers for Medicare and Medicaid Services (CMS) Inpatient Only List. There is no documentation provided to support the expectation that the enrollee will require a greater than 2 midnight stay. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient services have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient hospital services for a total shoulder arthroplasty procedure.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).

You asked the Plan to pre-approve admission to a SNF. You say that the requested admission to a SNF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF admission.

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 admission to a SNF. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to a SNF when she was discharged. The enrollee presented to the hospital because the enrollee's husband was unable to care for her at home, as she was unable to ambulate. The Physical Therapy Initial Evaluation Note includes a plan of "PT Frequency: 3-4x/week."

Based on the documentation provided, the enrollee does not require skilled nursing services. The enrollee would potentially benefit from skilled therapy services; however the documentation does not support that skilled therapy is required on a daily basis on an inpatient setting. As a practical matter, this enrollee does not require the necessary services on 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 admission to a SNF have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a knee orthosis (L1851).

You asked the Plan to pre-approve a knee orthosis (L1851). You say that the requested knee orthosis (L1851) is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested knee orthosis (L1851).

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 knee orthosis (L1851). Our reviewer says that the enrollee does not meet criteria for the requested knee orthosis (L1851). Our physician reviewer found the enrollee presented with right knee pain. Previous treatment included "surgery and 2 scopes". There was no instability documented on exam. The enrollee was diagnosed with unilateral primary osteoarthritis of the right knee. A medial unloader knee brace was to be provided. The case file does not contain documentation of joint laxity or instability. The enrollee does not meet criteria for the requested knee orthosis.

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 knee orthosis (L1851) have not been met. Therefore, we decided that the Plan does not have to pre-approve a knee orthosis (L1851).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).

You asked the Plan to pre-approve admission to a SNF. You say that the requested admission to a SNF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF admission.

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 admission to a SNF. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee is with a history of Ductal carcinoma in situ, depression, and osteoarthritis, who was admitted to the acute care hospital with generalized weakness, falls, and poor living conditions. Evaluation has been consistent with a dementing process. The enrollee has ambulated 40 feet with a rolling walker. An extended-care facility or a memory unit have been recommended for placement.

Based on the documentation provided, the enrollee does not require skilled nursing services. While the enrollee may benefit from skilled therapy services, the documentation does not support that such services are needed on a daily basis in an inpatient setting. As a practical matter, this enrollee does not require the necessary services on 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 admission to a SNF have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve imaging of parathyroid.

You asked the Plan to pre-approve imaging of parathyroid. You say that the requested imaging of parathyroid is medically necessary. The Plan denied your request. The Plan says the requested imaging of parathyroid is 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 imaging of parathyroid. Our reviewer says that the requested imaging of parathyroid is not medically necessary. Our physician reviewer found the parathyroid imaging is not used for diagnosis of hyperparathyroidism. The MD seems to doubt the diagnosis and getting a less specific test will likely only complicate the workup. If the planned tests ordered are suggestive, then imaging might be indicated to plan for surgery; however, at this point it seems as if the parathyroid hormone and calcium (when corrected for albumin 5.2) are within normal limits making the diagnosis unlikely.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of imaging of parathyroid have not been met. Therefore, we decided that the Plan does not have to pre-approve imaging of parathyroid.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Lorazepam tablets.

You asked the Plan to pre-approve Lorazepam tablets. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says Lorazepam tablets are not covered under the enrollee's Medicare Part B 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 Lorazepam tablets.

Benefits for Lorazepam tablets may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.