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

We decided that the Plan does not have to pay for an inpatient admission for an elective total hip arthroplasty.

You asked the Plan to pay for acute inpatient hospital care. You say that this is needed to prevent blood clots
after surgery. The Plan denied your request. The Plan says care could be provided without an inpatient stay
after the surgical procedure.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases,
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or
more.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our
physician reviewer found the total hip surgery may be safely performed with an observational stay. The
enrollee should have anticoagulation medication and observational stay at this time.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the
Plan does not have to pay for an inpatient admission for an elective total hip arthroplasty.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental services (D9222, D9223, D9610) 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 these services are not covered.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve
dental services (D9222, D9223, D9610) for the enrollee.
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 lumbar spinal stenosis.
The requested Superion spacer is experimental in nature, as more research is needed to show safety and
efficacy. The services are therefore not reasonable or medically necessary.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve a Vertiflex Superion spacer.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient psychiatric services.

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. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment.

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 was admitted to the hospital on May 6, 2021 with schizophrenia. Based on the submitted records, it is not expected that he will improve in a reasonable period of time beyond the dates in question, as he is not showing dangerousness to self or others and has no abnormal behaviors or hallucinations. He has no acute threats to safety. Active treatment was not taking place beyond the dates in question. The enrollee does meet the criteria for treatment in an acute inpatient mental health setting and the continued services are 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued inpatient psychiatric services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6549.

You asked the Plan to pre-approve the compression stockings. You say that this is needed before you leave the
hospital. The Plan denied your request. The Plan says this is not a covered benefit.

The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are
non-covered because they do not meet the statutory definition of a surgical dressing.

Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression
stockings identified with code A6549.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an upper denture.

You asked the Plan to pre-approve the upper denture. You say that you need this service to be approved for coverage. The Plan denied your request. The Plan says dentures are only allowed once every five years.

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, dentures are limited to once every 60 months. The record shows that you received a maxillary partial denture on June 19, 2017 and your upper denture benefit has been exhausted. Therefore, we decided that the Plan does not have to pre-approve an upper denture.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Dexcom G5 continuous glucose monitor (CGM).
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 you do not meet the criteria for coverage.
The Plan must follow Medicare rules. Medicare rules say that a therapeutic CGM is covered when specific
criteria are met.
We looked at the file and Medicare rules. The records show that you do not have a diagnosis of diabetes and
are not insulin-treated. 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 Dexcom G5
continuous glucose monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a very heavy-duty power wheelchair (K0808).

You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied
your request. The Plan says the weight limit has not been met.

The Plan must follow Medicare rules. The rules say that group two power wheelchairs are not covered.

The file shows that the weight limit for this non-covered wheelchair has not been met. Based on this
information, we decided that Medicare rules for coverage of the wheelchair have not been met. Therefore, we
decided that the Plan does not have to pre-approve a very heavy-duty power wheelchair (K0808).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Tymlos injection.

You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says there is no Part D pharmacy benefit with the plan.

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 Tymlos injection.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have 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 the enrollee does not meet Medicare criteria for the requested CGM.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections and does not require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of a CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation.

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 no documentation that the requested procedure is indicated at this time.

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 the LCD requires 2 sets of diagnostic medial branch blocks and the blocks have to cover the intended
target pain generator, achieving 80% pain relief. In this case, there was only one set performed and the L3-L4
level was not blocked in the first set. And most importantly, only 70% pain relief was achieved.

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 radiofrequency ablation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable controller (E2377) with expandable harness (E2313) and electronic connection (E2311) for a power wheelchair.
You asked the Plan to pre-approve an expandable controller with expandable harness and electronic connection. You say that the requested items are necessary for the enrollee's care. The Plan denied your request. The Plan says the requested items 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 an expandable controller with expandable harness and electronic connection. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the documentation does not reveal that the enrollee requires other types of proportional input devices (e.g., mini-proportional or compact joysticks, touchpads, chin control, head control, etc.) or non-proportional input devices (e.g., sip and puff, head array, etc.). The enrollee does not need to operate 3 or more powered seating actuators through the drive control, a separate display (i.e., for alternate control devices), other electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive control), or an attendant control. The enrollee's strength and function in the upper extremities with the ability to self-feed indicates that the enrollee can control any power options through their own individual switches. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an expandable controller with expandable harness and electronic connection have not been met. Therefore, we decided that the Plan does not have to pre-approve an expandable controller (E2377) with expandable harness (E2313) and electronic connection (E2311) for a power wheelchair.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vertiflex surgery.

You asked the Plan to pre-approve Vertiflex surgery. You say that this service is medically necessary. The Plan denied your request. The Plan says the requested surgery is considered experimental and investigational.

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 surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental. 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 Vertiflex surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve Vertiflex surgery.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CT scan of the heart.

You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your request. The Plan says this is considered a screening test.

The Plan must follow Medicare rules. Medicare rules say that CT scans 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 scan. Our reviewer says that the requested scan is not medically reasonable or necessary. Our physician reviewer found that in this case, you have hypertension, diabetes, hyperlipidemia, and obesity. You have had a stress test that is negative for ischemia. You do do not have one of the indications for the requested test as enumerated in the local coverage determination. The requested test is being used for screening purposes. The local coverage determination specifically excludes the requested test for screening purposes. 

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 scan have not been met. Therefore, we decided that the Plan does not have to pre-approve CT scan of the heart.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for ophthalmological services provided on October 20, 2020.

You asked the Plan to waive the co-payment for the ophthalmological services. The Plan denied your request. The Plan says per the Plan benefits, the co-payment applied correctly to the claim.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $15 co-payment for vision care.

You have been asked to pay a $15 co-payment for the ophthalmological services. The ophthalmological services falls within the vision care 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 co-payment for ophthalmological services provided on October 20, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Spinergy wheels and a ZRA frame for a wheelchair.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the evaluation did not mention the need for Spinergy wheels nor the ZRA frame.

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 the documentation does not reveal that you are unable to perform MRADLs in the home without the requested wheels and frame. The wheelchair evaluation from 11/20/20 does not indicate a requirement for these items. These items exceed your medical needs.

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 Spinergy wheels and a ZRA frame for a wheelchair.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.

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 admission is not medically necessary.

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 these services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the records show that you are in long-term care and have a right leg wound with infection. You are receiving oral medications and had stable vital signs. You need uncomplicated wound care. You need assistance with bed mobility and transfers and are not able to bear weight on your right leg. You have no skilled nursing or skilled therapy needs. You do not require skilled nursing or skilled therapy on a daily basis. As a practical matter, you do not require the necessary services on an inpatient basis at the SNF level of care.

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 skilled nursing facility (SNF) admission.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a replacement socket (L5700), test socket (L5620), lower extremity additions (L5645, L5673 and L5671) and Endo Bk Ultra (L5940).

You asked the Plan to pre-approve the lower limp prostheses. You say that you would like reconsideration because the requested items are medically necessary. The Plan denied your request. The Plan says the record does not show a change in physiological condition, irreparable wear of the device or part of the device or that the condition of the device or part of the device requires repairs and that the cost of the repairs would be more than 60% of the cost of replacement.

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 lower limp prostheses. Our reviewer says that the documentation does not support a need for the requested items. Our physician reviewer found documentation does not reveal a change in the physiological condition of the member resulting in the need for a replacement, an irreparable change in the condition of the device, or in a part of the device resulting in the need for a replacement; or, that the condition of the device, or the part of the device, requires repairs and the cost of such repairs would be more than 60 percent of the cost of a replacement device, or of the part being replaced. The documentation does not reveal why the prosthesis is unable to be repaired. 

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 lower limp prostheses have not been met. Therefore, we decided that the Plan does not have to pre-approve a replacement socket (L5700), test socket (L5620), lower extremity additions (L5645, L5673 and L5671) and Endo Bk Ultra (L5940).