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

We decided that the Plan does not have to pay for the lumbar sacral orthosis provided to the enrollee.

You asked the Plan to pay for the orthosis. You say that the orthosis was medically necessary. The Plan denied your request. The Plan says that you did not present medical records showing that the prescribing physician ever saw the member.

The Plan must follow Medicare rules. Medicare rules say that a spinal orthosis 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 pay for the orthosis. Our reviewer says that the orthosis was not considered medically reasonable and necessary in this case. An appropriate history and a physical examination of the back would reasonably be required to adequately assess whether the coverage criteria for an orthosis have been met. The documentation does not support that the lumbar-sacral orthosis was prescribed for one or more of the covered indications in this case, as there is insufficient documentation of a credible evaluation and a credible physical examination of the back. Our physician reviewer found that the enrollee's condition did not meet Medicare criteria for the 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 the orthosis have not been met. Therefore, we decided that the Plan does not have to pay for the lumbar sacral orthosis provided to the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve calf pads coded as E0995 for use with an approved power wheelchair.

You asked the Plan to pre-approve the calf pads. You say that the requested wheelchair is necessary. The Plan denied your request. The Plan says all requested items were approved aside from E0995, since this cannot be approved on initial issue of the wheelchair.

The Plan must follow Medicare rules. Medicare rules say that certain codes, including E0995, are for replacement items only. These codes cannot be used at the time of initial issue of the wheelchair.

Review of the file shows that this is an initial issue of a power wheelchair. As such, approval cannot be given for E0995. Therefore, we decided that the Plan does not have to pre-approve calf pads coded as E0995 for use with an approved power wheelchair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 2 power wheelchair with multiple power options (K0842) and accessories (E2377, E2313, E2311, E2361, E1007, E1028, E0955, E1012, E2601).
You asked the Plan to pre-approve a group 2 power wheelchair with multiple power options and accessories. You say that the enrollee needs this PWC. The Plan denied your request. The Plan says the records do not show that the criteria for this PWC have been met.
The Plan must follow Medicare rules. Medicare rules say that a Group 2 Multiple Power Option PWC is covered if all of the coverage criteria for a PWC are met and if the beneficiary either meets coverage criteria for a power tilt and recline seating system or uses a ventilator which is mounted on the wheelchair. A power seating system for tilt and recline will be covered if the beneficiary is at high risk for development of a pressure ulcer and is unable to perform a functional weight shift; or the beneficiary utilizes intermittent catheterization for bladder management and is unable to independently transfer from the wheelchair to bed; or the power seating system is needed to manage increased tone or spasticity. We looked at the file and Medicare rules. The records do not show that the enrollee uses a ventilator or meets the criteria for a power tilt and recline seating system. The submitted physical therapy records indicate that the enrollee is able to perform siting-to-standing transfers and weight shifts. The enrollee does not utilize catheterization and the record does not indicate that the power seating system is needed to manage increased tone or spasticity. Based on this information, we decided that Medicare rules for coverage of a group 2 power wheelchair with multiple power options and accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve a group 2 power wheelchair with multiple power options (K0842) and accessories (E2377, E2313, E2311, E2361, E1007, E1028, E0955, E1012, E2601).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) with leg appliance.

You asked the Plan to pre-approve a pneumatic compression device. You say that this device was deemed medically necessary for the enrollee. The Plan denied your request. The Plan says the denial of authorization for this device is correct, because the records do not show that a basic type pump would not work the enrollee.

The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required. 

We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) with leg appliance.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an initial 15 minutes of conscious sedation (D9239), an additional 15 minutes of conscious sedation (D9243 x 4), a therapeutic drug injection (D9230), and the removal of torus mandibularis (D7473).
You asked the Plan to pre-approve the dental services. You say that The Plan denied your request. The Plan says the requested dental services are not listed as covered service. The Plan says that if a dental item or service is not listed in the benefit chart then it is not covered.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested dental services are not among those covered under this benefit. The Customer Handbook clearly states that anesthesia is excluded from coverage. Additionally, the Customer Handbook clearly states that if a dental item or service is not listed in the benefit chart then it is not covered. Therefore, we decided that the Plan does not have to pre-approve an initial 15 minutes of conscious sedation (D9239), an additional 15 minutes of conscious sedation (D9243 x 4), a therapeutic drug injection (D9230), and the removal of torus mandibularis (D7473).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a removable tire insert (E2213).

You asked the Plan to pre-approve a removable tire insert. You say that the enrollee is not able to maintain air in the wheelchair tires and would bedbound in the event of a flat tire. The Plan denied your request. The Plan says rules for pre-approval have not been met.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The rules also say that additional expenses for "deluxe" features, or items that are rented or purchased for aesthetic reasons or added convenience, are not reasonable. 

The item at issue in this appeal does not serve a purpose that is primarily medical in nature. It appears this item is being requested for added convenience. Items requested for aesthetic reasons or added convenience are not considered medically necessary and reasonable. Therefore, we decided that the Plan does not have to pre-approve a removable tire insert (E2213).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips (A0120).

You asked the Plan to pre-approve additional routine transportation trips. You say that the requested additional transportation is necessary. The Plan denied your request. The Plan says the requested additional transportation trips exceed the benefit limit. Therefore, coverage criteria have not been met.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 48 one-way transportation trips per year. 

We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation trips (A0120).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve five additional home health skilled nursing visits.
You asked the Plan to pre-approve the additional visits. You say that this is medically necessary. The Plan denied your request. The Plan says your current education regarding disease management should meet clinical expectations with the now total twenty approved visits.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 additional visits. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found you do not have documented skilled nursing needs. As such, ongoing home health nursing services are not medically necessary or reasonable. 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 additional visits have not been met. Therefore, we decided that the Plan does not have to pre-approve five additional home health skilled nursing visits.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the cervical spine.

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 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has left-sided neck pain and a documented history of recent migraine with vertigo and breast cancer with treatment. The records do not document a differential diagnosis for which the requested CT was ordered. CT scan of the neck is indicated for the evaluation of acute cervical spine trauma where there is a higher than average likelihood of fracture or dislocation. In this case there is no specific clinical rationale for the requested CT scan of the neck. The CT scan is not reasonable or medically necessary.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the cervical spine.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve chiropractic services with an out-of-network (OON) provider.

You asked the Plan to pre-approve the OON chiropractic services. You say that you were able to see this provider before and there are no other specialists in your area. You say the closest one that the Plan recommends is 45 minutes away. The Plan denied your request. The Plan says there are in-network providers who are able to provide this service.

Medicare rules say that plans must make care accessible to enrollees. According to Medicare rules, care is considered accessible to an enrollee if contract providers are available within reasonable distance and travel time from the enrollee's home. The Plan says that enrollees must use contract providers. 

The provider is a non-contract provider. We were able to confirm that the Plan has contract providers located within reasonable distance and travel time from your home who can provide the OON chiropractic services. In this case, a reasonable distance and travel time for a chiropractic specialist in your area is within 45 minutes and 30 miles. This information is determined by Medicare using the local population density and care needs. The Plan was able to provide information for at least one in-network provider who is located within this range. Under Medicare rules, this means that contract providers are accessible to you. Therefore, we decided that the Plan does not have to pre-approve chiropractic services with an out-of-network (OON) provider. You may wish to contact the Plan for more information about in-network providers.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an interspinous spacer placement (22869).
You asked the Plan to pre-approve interspinous spacer placement. You say that the space placement is medically necessary. The Plan denied your request. The Plan says this procedure 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 interspinous spacer placement. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation of the enrollee's height, weight, or body mass index. There is no discussion indicating that a DEXA scan has demonstrated the lack of significant osteoporosis in this patient. The Superion device indirect lumbar decompression would not be considered the standard of care for the enrollee's medical 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 interspinous spacer placement have not been met. Therefore, we decided that the Plan does not have to pre-approve an interspinous spacer placement (22869).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM) sensor.
You asked the Plan to pre-approve CGM. You say that you need this because of your condition. The Plan denied your request. The Plan says the denial of authorization for this item is correct, because you are not on insulin 3 times per day with adjustments.
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 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. Based on this information, we decided that Medicare rules for coverage of CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM) sensor.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a spinal cord stimulator placement (63650, L8680) to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve the spinal cord stimulator placement. You say that this service is medically necessary. The Plan denied your request. The Plan says 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 a spinal cord stimulator placement (63650, L8680) to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued use of a continuous positive airway pressure device (CPAP).

You asked the Plan to pre-approve continue use. You say that this is medically necessary. The Plan denied your request. The Plan says no compliance report was provided.

The Plan must follow Medicare rules. Medicare rules say that CPAP use can be continued if there is documented compliance with the device.

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 continue use. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found you were diagnosed with obstructive sleep apnea (OSA) in 2011, and have presumably been on CPAP since then. Your device is more than five years old and requires replacement. However, there is no documentation of a clinical visit to confirm that you have been using and benefiting from the device, and there is no documentation that minimum usage requirements have been met. Without such documentation, the new device and associated supplies are 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 continue use have not been met. Therefore, we decided that the Plan does not have to pre-approve continued use of a continuous positive airway pressure device (CPAP).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health aide services.

You asked the Plan to pre-approve home health aide services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.

The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. 

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 home health aide services. Our reviewer says that the documentation does not support that the requested services are medically reasonable or necessary. Our physician reviewer found you received a Telehealth visit for a pre-operative evaluation. Right shoulder surgery is scheduled. The documentation does not support that you have documented skilled nursing or skilled therapy needs. Therefore, you do not meet criteria for the requested services. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home health aide services have not been met. Therefore, we decided that the Plan does not have to pre-approve home health aide services.
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 the SNF admission. You say that SNF care is medically appropriate for this enrollee. The Plan denied your request. The Plan says the guidelines for coverage of SNF care have not been met.
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 the SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee was recently admitted to the hospital and then to a skilled nursing facility on 2/2/21 due to worsening dementia. He was then discharged home with home health care services. The most recent therapy documentation indicates the member able to ambulate up to 50 feet independently. He is also independent with bed mobility, transfers and most self-care tasks. The member has stabilized medically and has been discharged home from the SNF and also from home health care services. The member does not require skilled nursing and/or skilled therapy services on a daily basis. He is medically stable and can receive further rehab services at a lower level of care. Although further rehab services would be appropriate to improve function, as a practical matter, the intermittent skilled services can be
provided at a lower level of care than a skilled nursing facility. Admission to a SNF for inpatient skilled rehab services is not medically necessary. He requires custodial 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 the SNF admission 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 Freestyle Libre 2 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 the services are not covered.

The Plan must follow Medicare rules. Medicare rules say that DME is replaced in cases of irreparable damaged or when the equipment has exceeded the reasonable useful lifetime period. 

We looked at the file and Medicare rules. The file shows that you currently have a Dexcom CGM that is two years old and not irreparably damaged. The requested Freestyle Libre 2 CGM is not covered because your current CGM does not need to be replaced. 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 Freestyle Libre 2 continuous glucose monitor (CGM).