Persius/hicric huggingface dataset:
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Apligraf skin graft.
You asked the Plan to pre-approve the Apligraf skin graft. You say that you would like reconsideration because the requested treatment is medically necessary. The Plan denied your request. The Plan says the record does not show that you failed standard conservative treatments for at least 30 days.
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 Apligraf skin graft. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the provided documentation did not clearly show that you had failed standard conservative treatments for at least 30 days. Wound volume was improved on recent notes with current treatment suggesting no failure of treatment. 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 Apligraf skin graft have not been met. Therefore, we decided that the Plan does not have to pre-approve the Apligraf skin graft.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve placement of the Superion interspinous spacer.

You asked the Plan to pre-approve the Superion procedure. You say that you feel that this treatment is necessary for you. The Plan denied your request. The Plan says this remains experimental 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 Superion procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Food and Drug Administration states that the Superion Interspinous Spacer is indicated to treat skeletally mature patients suffering from pain, numbness, and/or cramping in the legs (neurogenic intermittent claudication) secondary to a diagnosis of moderate lumbar spinal stenosis, with or without Grade 1 spondylolisthesis, confirmed imaging evidence of thickened ligamentum flavum, narrowed lateral recess, and/or central canal narrowing. The Superion Interspinous Spacer is indicated for those patients with impaired physical function who experience relief in flexion from symptoms of leg/buttock/groin pain, with or without back pain, who have undergone at least 6 months of non-operative treatment. The Superion Interspinous Spacer may be implanted at one or two adjacent lumbar levels in patients in whom operative treatment is indicated at no more than two levels, from L1 to L5. The Food and Drug Administration has stated that the device is contraindicated in individuals with morbid obesity defined as a body mass index (BMI) greater than 40. 

In this case, the enrollee indicates that the enrollee has chronic low back pain and lumbar spinal stenosis with neurogenic claudication. The record does not contain an imaging report. The record does not indicate that the enrollee experiences pain relief in flexion. The record indicates that the enrollee most recently has a body mass index of 41. The elements of the coverage criteria are not satisfied. 

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 procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve placement of the Superion interspinous spacer.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an ultra-lightweight wheelchair (K0005) and accessories.

You asked the Plan to pre-approve an ultra-lightweight wheelchair (K0005) and accessories. You say that the requested ultra-lightweight wheelchair (K0005) is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested ultra-lightweight wheelchair (K0005).

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 ultra-lightweight wheelchair (K0005) and accessories. Our reviewer says that the enrollee does not meet criteria for the requested ultra-lightweight wheelchair (K0005). Our physician reviewer found the criteria for the ultra-lightweight wheelchair (K0005) have not been met per Centers for Medicare and Medicaid Services, Local Coverage Determination (LCD): Manual Wheelchair Bases (L33788). The documentation does not support that the enrollee is a full-time manual wheelchair user. The documentation does not indicate that the enrollee requires individualized fitting and adjustments for one or more features such as axle configuration, wheel camber, or seat and back angles, and which cannot be accommodated by a K0001 through K0004 manual wheelchair. 

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 ultra-lightweight wheelchair (K0005) and accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve an ultra-lightweight wheelchair (K0005) and accessories.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve one additional OT visit.
You asked the Plan to pre-approve one additional OT visit. You say that you have a lot of medical problems with Lupus, severe arthritis, bad knee pain, and shoulder surgery. You say that you are having bad back pains again, and you are on six different types of medication and need to use a walker. The Plan denied your request. The Plan says additional occupational therapy services are not reasonable and necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 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 one additional OT visit. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the requested therapy is not generally accepted as specific and effective therapy for your condition. The records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or for physical therapy and occupational therapy, by or under the supervision of a therapist. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain your current condition or to prevent or slow further deterioration. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of one additional OT visit have not been met. Therefore, we decided that the Plan does not have to pre-approve one additional OT visit
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that you are in the hospital. You say that you need rehabilitation (rehab) as soon as possible for your hip fracture. You say that if you do not receive rehab soon, your mobility will be compromised. The Plan denied your request. The Plan says you do not require an intensive rehabilitation program to return to preadmission baseline. The Plan says that you do not have complex medical management needs. The Plan also says that you do not require supervision by a rehabilitation physician.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.

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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the provided documentation indicates that the enrollee is medically stable and does not have complex nursing or rehabilitation needs. The reviewer found that there is no documented need for a intensive, multi-disciplinary rehabilitation program. The reviewer also found that there is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Specifically, the file shows that there is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that the inpatient rehab would help get you back to baseline level of function. You also say that you feel you will not receive the level care of needed at a subacute/SNF care. The Plan denied your request. The Plan says the IRF stay is not medically reasonable or necessary.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee is medically stable and has no complex nursing or rehabilitation needs.

The reviewer found that there is no documented need for a intensive, multi-disciplinary rehabilitation program. The reviewer also found that there is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Therefore, the reviewer found that the IRF care is not medically reasonable or necessary. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Specifically, the file shows that there is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Intraosseous ablation of the basivertebral nerve, the Intracept procedure.
You asked the Plan to pre-approve Intraosseous ablation of the basivertebral nerve, the Intracept procedure. You say that the requested Intraosseous ablation of the basivertebral nerve, the Intracept procedure, is medically necessary. The Plan denied your request. The Plan says the requested Intraosseous ablation of the basivertebral nerve, the Intracept 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 Intraosseous ablation of the basivertebral nerve, the Intracept procedure. Our reviewer says that the requested Intraosseous ablation of the basivertebral nerve, the Intracept procedure, is not medically necessary.
Our physician reviewer found the enrollee has chronic low back. He has a history of prostate cancer. He has
tried physical therapy (PT) and a home exercise program, radiofrequency ablation (RFA) of the Medial
Branches, and Epidural Steroid Injections. He has tried Chiropractic Therapy. He takes Gabapentin, Percocet
and Advil for pain. He has Modic changes on his MRI at L4-L5. The request is for RFA of the basivertebrtal
nerves at L4 and L5. This is considered an experimental/investigational procedure. Therefore, the procedure is
deemed not medically reasonable or necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Intraosseous ablation of the basivertebral nerve, the Intracept procedure have
not been met. Therefore, we decided that the Plan does not have to pre-approve Intraosseous ablation of the
basivertebral nerve, the Intracept procedure.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that an IRF admission is medically necessary. The Plan denied your request. The Plan says an IRF admission is not medically necessary.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for altered mental status, pneumonia and right leg cellulitis. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve Freestyle Libre continuous glucose monitor (CGM) supplies.
You asked the Plan to pre-approve the CGM supplies. You say that you have been using this CGM system since 2017 and have no other glucose meter. You also state that the decision was made using outdated information because your doctor stated that the Plan did not reach out to them about this request. The Plan denied your request. The Plan says that a call was made to another department within the Plan which indicates that the enrollee is not using insulin. It is not felt medical records are needed to confirm this.
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. The Plan's denial is based on information about how often insulin is used. The Plan did not make any efforts to obtain actual clinical documentation to support this. As this request for supplies was originally denied in June 2021, we find that it is not within the enrollee's best interest to delay a decision to allow for the Plan to obtain documentation that would validate the denial. As such, we find this denial is not substantiated. Therefore, we decided that the Plan has to pre-approve Freestyle Libre continuous glucose monitor (CGM) supplies.
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 2 extractions and a full-arch dental implant.
You asked the Plan to pre-approve the dental services. You say that you only have half of the bone structure for your upper and lower jaw. You say that this is why you need implants. You also say that the denture is medically necessary. The Plan denied your request. The Plan says the requested dental services are routine in nature. The Plan also says that routine dental services are not covered by Medicare.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve 2 extractions and a full-arch dental implant
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that you need more rehabilitation than what you are getting in the hospital and if you did the rehabilitation by yourself then you would not get the necessary exercise. The Plan denied your request. The Plan says based on Medicare guidelines, the IRF services you and/or your provider are requesting do not meet the requirements for approval.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that based on the documentation provided, the health Plan's denial should be upheld. You do not require the intensity of services provided at an IRF.
Specifically, you are not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. Your care needs can be met at a lower level of care (ex. skilled nursing facility/sub-acute rehabilitation). We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the crown (D2740) provided on June 1, 2021.
You asked the Plan to pay for the crown. You say that it was not clear that you could only receive either two crowns or two fillings per year, not both. The Plan denied your request. The Plan says that you have reached the limit for this service.
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. The EOC states that you are limited to up to 2 visits for restorative services every year. The contract does not clearly state that you are limited to only 2 restorations every year. You reasonably believed the crown would be covered because the contract does not clearly state that restorative services are limited to two procedures per year. We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the crown have been met. Therefore, we decided that the Plan has to pay for the crown (D2740) provided on June 1, 2021.
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 the all-lower extremity prostheses, flex-walk system or equal (L5981)
You asked the Plan to pre-approve the advanced foot feature. You say that please reconsider the denial of a new prosthetic foot for the enrollee. The medical records you sent shows that the enollee meets the criteria. The Plan denied your request. The Plan says a K3 foot exceeds the enrollee's needs and does not meet the Medicare criteria of reasonable and 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 the advanced foot feature. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee's prosthetist states that K3 foot is indicated for the enrollee. Office visit notes from enrollee's physician specifically state that enrollee "needs crutches and a manual wheelchair. The enrollee has a motorized wheelchair and right leg prosthesis. This is inconsistent with K3 ambulatory function. Needs can be met with K2 prosthesis. Per Medicare guidelines, "Records from suppliers or healthcare professionals with a financial interest in the claim outcome are not considered sufficient by themselves for determining that an item is reasonable and necessary." The prosthetist is the vendor and therefore has financial interest in the outcome of the claim. 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 advanced foot feature have not been met. Therefore, we decided that the Plan does not have to pre-approve the all-lower extremity prostheses, flex-walk system or equal (L5981)