Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the depth and breadth of the care the enrollee requires would be best provided in the LTACH setting. The Plan denied your request. The Plan says the enrollee can remain in the current setting indefinitely.
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 patient in this case is a 60-year-old female with diagnosed MS who was admitted to the current acute care hospital for a sacral wound requiring management. She was diagnosed with necrotizing abscess and treated with debridement, wound VAC, and antibiotics. Her stay has been complicated with a perforated rectum and infection and treated with colectomy and colostomy. She required a feeding tube. CT showed evidence of osteomyelitis. IV antibiotics were continued. MRI showed lipomatous infiltration about the gluteal soft tissues. The patient appears to be requiring additional acute care services but is not stable enough to transfer at this time. The patient does not require services at the LTACH that are not available at the current facility. Therefore, as there would be no advantage to transferring to LTACH at this time, the LTACH services will be considered not medically necessary. The patient may be able to transfer to a lower level of care at a later date when more stable. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH 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 admission to a LTACH is not medically necessary. Our physician reviewer found the enrollee is with a history of chronic ventilation support who was admitted to the current acute care hospital with aspiration pneumonia, sepsis, and anemia. He was treated with antibiotics, blood transfusion, thoracentesis and breathing treatments. He currently requires BiPAP at night and is weaning down on oxygen supplementation. Anemia is severe but stable. The enrollee appears to be improving with current acute care services. It is unlikely, based on the recent reports, that this enrollee will require an additional 25 or more days of acute care services. The enrollee does not require services at the LTACH that are not available at the current facility. There are no services at the LTACH that the enrollee requires that are not already being provided and covered at the current facility. Therefore, as there would be no advantage to transferring to LTACH at this time, the LTACH services will be considered not 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 the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the PET scan with concurrently acquired CT for attenuation correction and anatomical localization imaging; skull base to mid-thigh (78815) to the enrollee on April 3, 2020.
You asked the Plan to pay for the PET scan. You say that the claim should be paid. 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 PET scan have not been met. The rules say that PET procedures performed to inform the initial treatment strategy of tumors (modifier PI) must be reported with an appropriate diagnosis. C50.911 Malignant, unspecified is not listed as an appropriate diagnosis. Therefore, we decided that the Plan does not have to pay for the PET scan with concurrently acquired CT for attenuation correction and anatomical localization imaging; skull base to mid-thigh (78815) to the enrollee on April 3, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on February 12, 2020.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the place of service
must reflect the location where the specimen was obtained.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate code.
The documentation provided does not show that the lab specimen was taken at an independent lab. 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 pay for the lab services provided on February 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CardioMems device for the enrollee.
You asked the Plan to pre-approve this device. You say that this device is medically necessary. The Plan denied your request. The Plan says this device is not covered by Medicare.
The Plan must follow Medicare rules. Medicare does not cover investigational services or devices. 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 this device. Our physician reviewer found data obtained from a CardioMems device has been demonstrated in only one trial to help reduce hospital readmission compared to standard medical therapy. Concerns have been raised about potential bias in this trial calling into question the results. The efficacy of the CardioMems device is uncertain at this time according to leading authorities and not recommended in current guidelines for the treatment of heart failure. Medicare coverage criteria are not met, since the device should still be considered experimental or investigational. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this device have not been met. Therefore, we decided that the Plan does not have to pre-approve a CardioMems device for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on September 9, 2019.
You asked the Plan to pay for the office visit. 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 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
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 an office visit provided on September 9, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor for the enrollee.
You asked the Plan to pre-approve a continuous glucose monitor. You say that this equipment is medically necessary for the enrollee. The Plan denied your request. The Plan says Medicare coverage criteria are not met as the enrollee does not use insulin.
The Plan must follow Medicare rules. Medicare covers the requested CGM for enrollee's treatment with insulin. Based on the records provided, the enrollee is not treated with insulin. Medicare rules for coverage of a continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic cervical traction device.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says the medical records provided do not indicate that criteria has 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 the device. Our reviewer says that the requested pneumatic cervical traction device not considered medically reasonable and necessary in this case. Our physician reviewer found you do not have a physician or dentist physical exam findings. There is no documentation indicating a diagnosis of TMJ dysfunction, or that you have received treatment for this condition.
You do not have a distortion of the lower jaw or neck anatomy (e.g. radical neck dissection) such that a chin halter is unable to be utilized. The documentation is not clear that the appropriate use of the device has been demonstrated. There is no evidence you can tolerate the device, or that you require greater than 20 pounds of cervical traction in the home 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 the device have not been met. Therefore, we decided that the Plan does not have to pre-approve a pneumatic cervical traction device.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pre-approve CYP2C19 testing. 
 
You asked the Plan to pre-approve CYP2C19 testing. The Plan denied your request. The Plan says that this is 
not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that CYP2C19 testing is covered for the above 
indications. 
 
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 CYP2C19 testing. Our reviewer says 
that the requested CYP2C19 testing is medically reasonable and necessary. Our physician reviewer found that 
although the enrollee has not had an MRI, he has had end organ disease as a result of vascular disease. Plavix 
(clopidrogel) is indicated. This test will help see if this enrollee is a likely non-responder or poor responder. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CYP2C19 testing have been met. Therefore, we decided that the Plan has to 
pre-approve CYP2C19 testing.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that you need the orthotics because you have a torn 
meniscus. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex Superion device. 
 
You asked the Plan to pre-approve a Vertiflex Superion device. The Plan denied your request. The Plan says 
this 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 a Vertiflex Superion device. Our 
reviewer says that the requested device is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that current evidence-based medical guideline and peer reviewed literature do not 
fully support the spinal decompression device procedure over the gold standard of lumbar laminectomy. 
Additionally, FDA indications have not been met, as the enrollee has severe spinal stenosis at the L2/3 level. 
There is no rationale why standard surgical decompression would not be indicated. 
 
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 Vertiflex Superion device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a Vertiflex Superion device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to provide Group 2 standard power wheelchair accessories. 
 
You asked the Plan to provide Group 2 standard power wheelchair (K0823) accessories. You say that the code 
for the wheelchair was accidentally entered wrong and you will request the correct power wheelchair. The Plan 
denied your request. The Plan says the power wheelchair requested will not meet the enrollee's weight 
requirement therefore the accessories cannot be approved. 
 
The Plan follows Medicare rules. Medicare rules say options and accessories for wheelchairs are covered if the 
beneficiary has a wheelchair that meets Medicare coverage criteria and the option/accessory itself is medically 
necessary. 
 
The file shows that the original requested Group 2 standard power wheelchair is not approved. This means that 
Medicare rules for coverage of the accessories have not been met. Therefore, we decided that the Plan does not 
have to provide Group 2 standard power wheelchair accessories.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Superion Spacer. 
 
You asked the Plan to pre-approve the Superion Spacer. You say that you would like reconsideration because 
pain medication, injections and other procedures have not helped your condition. The Plan denied your request. 
The Plan says there remains a lack of studies which compare interspinous spacers to standard treatments. 
 
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 Superion Spacer. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this device remains experimental and more research is needed to show safety and 
efficacy. 
 
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 Superion Spacer have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Superion Spacer.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transcranial magnetic stimulation (TMS) treatment 
(90869, 90868, 90867). 
 
You asked the Plan to pre-approve TMS treatment. You say that the requested treatment is medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that transcranial magnetic stimulation (TMS) cannot be 
covered unless there is a trial of psychotherapy. 
 
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 TMS treatment. Our reviewer says that 
the requested treatment is not medically necessary. Our physician reviewer found there is no documented 
history of counseling or therapy. Coverage criteria requires previous treatment utilizing psychotherapy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of TMS treatment have not been met. Therefore, we decided that the Plan does not 
have to pre-approve transcranial magnetic stimulation (TMS) treatment (90869, 90868, 90867).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a heavy duty rollator. 
 
You asked the Plan to pre-approve a walker with seat. You say that the enrollee needs a walker also. The Plan 
denied your request. The Plan says the enrollee was approved for a scooter in 2019 and there is no evidence 
that the scooter is not meeting the enrollee's mobility needs to carry out mobility related activities of daily 
living. 
 
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. Medicare rules say that a power mobility device will not be covered if the patient?s 
condition can be ameliorated by a walker. 
 
The enrollee's scooter is still within the 5-year RUL and the documentation submitted does not show that the 
scooter is irreparably worn or irreparably damaged.  The scooter serves the same purpose as a rollator. 
Therefore, we decided that the Plan does not have to pre-approve a heavy duty rollator.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve Magnetic Resonance Imaging (MRI) of the abdomen (74183). 
 
You asked the Plan to pre-approve the MRI. You say that the MRI is medically necessary. The Plan denied 
your request. The Plan says that rules for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
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 MRI. Our reviewer says that in this 
case, the MRI is medically necessary. Our physician reviewer found an enlarging pancreatic cystic lesion 1-
2cm in size warrants a medically necessary MRI re-examination in 1 year. The requested MRI is appropriate. 
 
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 MRI have been met. Therefore, we decided that the Plan has to pre-approve 
Magnetic Resonance Imaging (MRI) of the abdomen (74183).  
 
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: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a replacement lace-up front corset. 
 
You asked the Plan to pre-approve a replacement lace-up front corset. You say that you have low back pain and 
use the corset as a brace. The Plan denied your request. The Plan says that a lace-up corset is not considered a 
rigid or semi rigid brace and not covered under Medicare guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We looked at the file and Medicare rules. There is a physician order for the corset. Based on this information, 
we decided that Medicare rules for coverage of a replacement lace-up front corset have been met. Therefore, 
we decided that the Plan has to pre-approve a replacement lace-up front corset.  
 
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for repeat medial branch blocks.
You asked the Plan to pay for the repeat medial branch blocks. You say that you would like reconsideration
because you are experiencing extreme lower back pain and your specialist has stated you need these injections.
The Plan denied your request. The Plan says the service requested is inconsistent with what is documented in
the clinical documentation.
The Plan follows Medicare rules. Medicare rules say that for Medicare to consider coverage and payment for
any item or service, the information submitted by the supplier or provider must corroborate the documentation
in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been 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 pay for the repeat medial branch blocks. Our
reviewer says that the provider requested repeat diagnostic injections. Our physician reviewer found the service
requested is inconsistent with what is documented in the clinical documentation.
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 repeat medial branch blocks have not been met. Therefore, we decided that
the Plan does not have to pay for repeat medial branch blocks.