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

We decided that the Plan does not have to pre-approve Freestyle libre 14-day sensor kit.

You asked the Plan to pre-approve the sensor. You say that it is very bothersome for the enrollee to check their glucose because they have significant pain with finger pokes. You state you believe their quality of life and glucose control would improve with a continuous monitor. The Plan denied your request. The Plan says the Medicare rules have not been met.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan. 

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin injections three or more times per day or use a Medicare-covered insulin pump.

Based on this information, we decided that Medicare rules for coverage of the sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve Freestyle libre 14-day sensor kit.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation feature (E2300) for the enrollee.

You asked the Plan to pre-approve a power seat elevation feature. You say that this is medically necessary for
the enrollee. The Plan denied your request. The Plan says that seat elevators are not medically necessary and
cannot be covered.

The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature is non-covered
because it is not primarily medical in nature. Therefore, we decided that the Plan does not have to pre-approve
a power seat elevation feature (E2300) for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided on March 22, 2021, to March 23, 2021.

You asked the Plan to pay for acute inpatient hospital care. You say that these services were medically necessary. The Plan denied your request. The Plan says these services could have been provided as an outpatient.

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 enrollee underwent irrigation and debridement of the wound without complication, and was treated with fluids, a tetanus booster, and antibiotics. Our physician reviewer found there was no report of a failure of outpatient treatment or treatment plans which would require hospital treatment that would be expected to cross two midnights. 

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 the acute inpatient hospital care provided on March 22, 2021, to March 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial periapical x-ray (D0220), the additional periapical x-ray (D0230), and the crown (D2740) provided on March 8, 2021.
You asked the Plan to pay for the dental services. You say that the enrollee presented for a crown as their previous one had come off cleanly. You say that there was recurrent decay under the crown. You also say that while the crown was outside the frequency, redoing the crown could not be avoided. The Plan denied your request. The Plan says 1 periapical x-ray is covered per calendar year. The Plan says that 2 crowns are covered per calendar year. The Plan also says that the frequency limits for these services have been exceeded.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage and the services are listed as covered, the frequency limits have been exceeded. The record shows that the Plan paid for a periapical x-ray and 2 crowns that you received on January 11, 2021. Therefore, we decided that the Plan does not have to pay for the initial periapical x-ray (D0220), the additional periapical x-ray (D0230), and the crown (D2740) provided on March 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 2 single power option power wheelchair (K0835) and accessories (E2361, E23211, E1002, E1028, E1012, E0955, E2624).
You asked the Plan to pre-approve a group 2 single power option power wheelchair and accessories. You say that these items are medically necessary. The Plan denied your request. The Plan says the requirements for coverage have not been met.
The Plan must follow Medicare rules. Medicare rules say that a group 2 single power option power wheelchair is covered if the beneficiary either requires a drive control interface other than a hand or chin-operated standard proportional joystick (examples include but are not limited to head control, sip and puff, switch control) or meets the coverage criteria for a power tilt or a power recline seating system and the system is being used on the wheelchair. A power tilt and/or recline seating system is covered if the beneficiary is at high risk for development of a pressure ulcer and is unable to perform a functional weight shift, utilizes intermittent catheterization for bladder management and is unable to independently transfer from the wheelchair to bed, or needs the system to manage increased tone or spasticity.
We looked at the file and Medicare rules. The records do not show that the enrollee requires a drive control interface other than a hand or chin-operated standard proportional joystick or that the criteria for a power tilt or recline system have been met. While the records reference the risk of pressure ulcers, the submitted evaluation indicates that the enrollee is capable of and independent with weight shifts. Based on this information, we decided that Medicare rules for coverage of a group 2 single power option power wheelchair and accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve a group 2 single power option power wheelchair (K0835) and accessories (E2361, E23211, E1002, E1028, E1012, E0955, E2624).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on May 24, 2021.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that the various denied CPT codes are not supported in the medical record. Specifically, the testing at issue in this case should be reported with CPT 81479. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on May 24, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on March 5, 2021.

You asked the Plan to pay for physician's services. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. 

The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for physician's services provided on March 5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Volara system for the enrollee.

You asked the Plan to pre-approve the system. You say that this is medically necessary. The Plan denied your request. The Plan says the specific equipment requested lacks sufficient evidence to support medical necessity.

The Plan must follow Medicare rules. Medicare rules say the HFCWODs are covered only when they are medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases.

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 system. Our reviewer says that the requested system is not medically reasonable or necessary. Our physician reviewer found the enrollee has asthma, allergic bronchopulmonary aspergillosis, and bronchiectasis with mucous impaction.

There is no evidence in the medical record that traditional measures of airway clearance, such as flutter valve or manual percussion and postural drainage, have been tried and failed. The Volara system incorporates 3 treatments, positive expiratory pressure, airway flow oscillation, and nebulization of medications. It has not been demonstrated to be beneficial in the home treatment of lung disease.

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 system have not been met. Therefore, we decided that the Plan does not have to pre-approve the Volara system for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sclerotherapy for the enrollee.

You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your request. The Plan says this procedure for cosmetic purposes is not considered 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 the surgery. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is recently status post 5 separate Clarivein closures on five separate days described as right below, left below, right lesser, left lesser, and right above on dates ranging from 7/14/2021-9/8/2021. The enrollee is described as having phlebitis and thrombophlebitis. A duplex exam report is not provided demonstrating successful closure of truncal veins and demonstrating absence of deep vein thrombosis (DVT). It is not clear that despite all of the above procedures, the enrollee continues to have lifestyle-limiting pain despite compression stocking use. It is not clear that sufficient time has been given to recover from the thrombophlebitis and recent ablative treatment prior to making decisions about further treatments. 

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 surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve sclerotherapy for the enrollee.
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 requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.

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 there is no need for physician supervision 3 times per week (at a minimum) for the ongoing management of any active or acute exacerbation of chronic medical condition. Your rehab needs can be safely met in an alternate and low intensity setting such as a skilled nursing facility. 

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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Omniseq Insight Panel for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary for determining the most appropriate treatment pathway. The Plan denied your request. The Plan says this testing is unlikely to impact medical decision-making and treatment options.
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 OmniSeq Insight panel interrogates the coding region of 523 genes by next generation sequencing for mutations, select copy number alterations, and fusions/splice variants. It has not been demonstrated that the number of genes being tested is reasonable and necessary to obtain necessary information for therapeutic decision making regarding the enrollee in this case. 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 the Omniseq Insight Panel for the enrollee.
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 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 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 medically necessary. Our physician reviewer found the records show that you were admitted to the hospital with slurred speech and coordination problems. You are now medically stable with no complex nursing or rehabilitation needs. You do 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 you 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve the CardioMEMS device for the enrollee.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says that this is considered investigational with additional studies needed.
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 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 services are considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has New York Heart Association (NYHA) Class III heart failure, with preserved ejection fraction. The enrollee is on a high dose oral diuretic regimen, with a hospitalization in the past year for decompensated congestive heart failure. Management of her heart failure with standard medical therapy and relying on symptoms, weights and signs has not been effective in keeping her with minimal symptoms and has resulted in ongoing life limiting symptoms and an acute hospitalization. Cardiomems device monitoring in this situation can provide additional heart filling pressure data to better manage very complex regimens to optimize fluid status. Data from the Champions trial along with longer term follow-ups studies have shown a significant decrease in hospitalizations and improvement in heart failure symptoms and NYHA Class with the use of this device. There is also published expert opinion in the cardiology literature as to its appropriate use as well as reasonable patient selection criteria, and FDA approved indications all of which are met in this clinical instance. It would therefore not be considered investigational for this indication and would meet the medical reasonableness and necessity criteria of the applicable CMS Section 1862(a) 1(A) rule. 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 been met. Therefore, we decided that the Plan has to pre-approve the CardioMEMS device for the enrollee.
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 pre-approve percutaneous laminotomy/laminectomy (CPT code 0275T), for the enrollee.

You asked the Plan to pre-approve the service. You say that the enrollee has radio-logically confirmed lumbar spinal stenosis at the T12 and A1 level with associated moderate to severe pain. You state the enrollee's condition has progressed such that activities of daily living are limited due to intensity of discomfort. The Plan denied your request. The Plan says the type of procedure requested is only supported when the enrollee is part of an approved clinical trial and the enrollee's records do not show this.

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 service have not been met. The enrollee's records do not show they are enrolled in a clinical trial. Therefore, we decided that the Plan does not have to pre-approve percutaneous laminotomy/laminectomy (CPT code 0275T), for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided in an outpatient setting
from April 20, 2021, to April 22, 2021.
You asked the Plan to pay for the self-administered drugs. You say that the medication you are being billed for
must have been given in the operating room or the recovery room during surgery. You say that you did not
receive any medication that you took by mouth during the rest of the time you were in the hospital. You also
say that you should not have to pay for these charges. The Plan denied your request. The Plan says the
medications you received are considered self-administered.
The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan
also says the medications you received are not covered under Medicare Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 pay for the self-administered drugs
provided in an outpatient setting from April 20, 2021, to April 22, 2021.
Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that
administers Part D benefits for further information concerning any benefits and appeal rights.