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

We decided that the Plan does not have to pre-approve the power seat elevation system (E2300), transit
securement package (K0108), expandable controller (E2377), electronic connection (E2311), and harness
(E2313).
You asked the Plan to pre-approve the power seat elevation system, transit securement package, expandable
controller, electronic connection, and harness. You say that the items are medically necessary. The Plan denied
your request. The Plan says there is not a medical need to control these power options through the joystick and
the transit option and power seat elevation system do not serve a medical need.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose.
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 power seat elevation system, transit
securement package, expandable controller, electronic connection, and harness. Our reviewer says that the
member does not need these items. Our physician reviewer found the patient's wheelchair has 3 power options
but the patient's function in the upper extremities supports that the patient 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 the power seat elevation system, transit securement package, expandable
controller, electronic connection, and harness have not been met. Therefore, we decided that the Plan does not
have to pre-approve the power seat elevation system (E2300), transit securement package (K0108), expandable
controller (E2377), electronic connection (E2311), and harness (E2313).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the manual adult-sized wheelchair including tilt in space
and accessories.
You asked the Plan to pre-approve the manual adult-sized wheelchair including tilt in space and accessories.
You say that the items are medically necessary. The Plan denied your request. The Plan says Medicare does not
cover durable medical equipment (DME) in a skilled nursing facility (SNF) based on statutory definition of
DME.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.
Records show that the manual adult-sized wheelchair including tilt in space and accessories is being requested
for use in a SNF or hospital. Therefore, we decided that the Plan does not have to pre-approve the manual
adult-sized wheelchair including tilt in space and accessories.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor and sensor (A9276,
A9277, A9278).
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 criteria is not met.
The Plan must follow Medicare rules. The rules say that HCPCS A9276, A9277, and A9278 are not covered
codes.
The requested monitor is coded in such a way that makes it statutorily not covered by Medicare. 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 a continuous glucose monitor and sensor
(A9276, A9277, A9278)
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve fluid circulating cold pad with pump (E0218).
You asked the Plan to pre-approve fluid circulating cold pad with pump. You say that you had surgery on
10/01/2021 and it is swollen. Your doctor ordered this item to help with the pain as well. The Plan denied your
request. The Plan says the requested cold therapy machine does not meet Medicare's definition of medical
necessity.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of fluid circulating cold pad with pump have not been met. Therefore, we decided that the Plan does
not have to pre-approve fluid circulating cold pad with pump (E0218).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a foot box, detachable arm rest, safety belt, and
positioning for a seat cushion and back rest.
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. The rules say Medicare covers DME only when it is reasonable and
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered
reasonable and necessary.
The requested items are included in the Group 3 power wheelchair that has been approved by the Plan. The
items are not separately billable. Therefore, we decided that the Plan does not have to pre-approve a foot box,
detachable arm rest, safety belt, and positioning for a seat cushion and back rest.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Entyvio.
You asked the Plan to pre-approve Entyvio. You say that this is medically necessary. The Plan denied your
request. The Plan says that this is not being prescribed for a medically-accepted indication.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.
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 Entyvio. Our reviewer says that
Entyvio is not medically reasonable and necessary. You have a history of lymphocytic colitis. Entyvio is
indicated for the treatment of adult patients with moderately to severely active Crohn's disease who have had an
inadequate response with, lost response to, or were intolerant to either conventional therapy or a tumor necrosis
factor-alpha (TNFa) antagonist. The requested use of Entyvio is not FDA-approved for your diagnosis. Its use
is not supported by one of the major drug compendia or by clinical research that appears in a Centers for
Medicare & Medicaid Services approved medical journal. Our physician reviewer found that your condition
does not meet criteria for coverage of Entyvio.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Entyvio have not been met. Therefore, we decided that the Plan does not have
to pre-approve Entyvio.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says you do not have
a need for daily skilled nursing or therapy services.
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 SNF services. Our physician reviewer
found that you do not require skilled nursing services of a skilled professional nurse to provide medically
necessary treatment. Your functional level, with an inability to follow commands, does not require skilled
therapy services with a qualified therapist to provide medically necessary treatment. You do not require skilled
nursing or skilled therapy services on a daily basis.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power operated vehicle (K0800).
You asked the Plan to pre-approve a power operated vehicle. You say that you need this to go to the doctor and go shopping independently. The Plan denied your request. The Plan says the requirements have not been met.
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. The records show item at issue in this appeal is for community use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pre-approve a power operated vehicle (K0800).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the electric connection (E2311), expandable controller
(E2377), and harness (E2313).
You asked the Plan to pre-approve the electric connection, expandable controller, and harness. You say that the
items are medically necessary. The Plan denied your request. The Plan says there is not a medical need to
control the power options through a joystick.
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 electric connection, expandable
controller, and harness. Our reviewer says that the items are not medically necessary. Our physician reviewer
found the patient's strength in the upper extremities supports that the patient 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 the electric connection, expandable controller, and harness have not been met.
Therefore, we decided that the Plan does not have to pre-approve the electric connection (E2311), expandable
controller (E2377), and harness (E2313).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genicular nerve radiofrequency ablation (RFA).
You asked the Plan to pre-approve genicular nerve RFA. You say that the enrollee has tried and failed
conservative treatment, but a prior genicular nerve block provided 80% pain relief. The Plan denied your
request. The Plan says the denial of authorization for this service is correct, because genicular RFA is still
being studied to determine if it is safe and effective.
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 genicular nerve RFA. Our reviewer
says that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found genicular nerve radiofrequency ablation is considered investigational and not
necessary for treatment of knee pain.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of genicular nerve RFA have not been met. Therefore, we decided that the Plan
does not have to pre-approve genicular nerve radiofrequency ablation (RFA).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Purewick external female urine collection device.
You asked the Plan to pre-approve incontinence supplies. You say that your mother is 91 years old, and diapers
do not work for her because she wakes up wet and cold. Catheters have been working for her and she is almost
of catheters. The Plan denied your request. The Plan says Purewick is not covered by Original Medicare due to
the lack of scientific evidence of benefit.
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered
because they are hygienic items that are non-reusable.
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of
these items. Therefore, we decided that the Plan does not have to pre-approve the Purewick external female
urine collection device
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does
not meet criteria.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found the enrollee requires short-term additional acute care services until long-term
placement is decided. There are no services at the LTACH that the enrollee requires that are not already
available and covered at the current 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 the LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve long term acute care hospital (LTACH) services
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incision (opening in skin) for implantation (placed under the skin) of cranial nerve neurostimulator (device that triggers nerves in the brain) (CPT code 64568) and insertion (placement) of chest wall respiratory sensor electrode (detects changes in breathing) or electrode array (multiple electrodes) (CPT code 0466T), for the enrollee.

You asked the Plan to pre-approve the services. You say that Medicare allows for home sleep studies. The Plan denied your request. The Plan says a home sleep study does not meet Medicare LCD criteria for sleep apnea testing for this particular procedure.

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 physician reviewer found the clinical documentation does not include polysomnography performed within twenty-four (24) months of the first consultation for the hypoglossal nerve stimulation implant.

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 incision (opening in skin) for implantation (placed under the skin) of cranial nerve neurostimulator (device that triggers nerves in the brain) (CPT code 64568) and insertion (placement) of chest wall respiratory sensor electrode (detects changes in breathing) or electrode array (multiple electrodes) (CPT code 0466T), for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Quike QX lightweight folding manual wheelchair.
You asked the Plan to pre-approve these services. You say that you need a lighter wheelchair to assist the enrollee. The Plan denied your request. The Plan says the item is not covered.
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. The file shows that the enrollee has a manual wheelchair. The lightweight folding wheelchair serves the same purpose as the manual wheelchair. Therefore, we decided that the Plan does not have to pre-approve a Quike QX lightweight folding manual wheelchair.
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 enrollee does not meet criteria for IRF admission.
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
enrollee does not meet criteria for IRF admission. Our physician reviewer found based on the documentation
provided, the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is
not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The
enrollee's care needs can be met at a lower 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 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.

You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says the care you require is custodial.

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 SNF services. Our physician reviewer found that you do not require the skilled nursing services of a skilled professional nurse to provide medically necessary treatment. Your cognitive level and difficulty following commands is impairing full participation in therapy at this time. You are noted to be disoriented and it is not evident that you can carry over of skilled daily therapies. Your functional level does not require skilled therapy services with a qualified therapist. You do not require skilled nursing or therapy services on a daily basis in a SNF setting. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 4 skilled physical therapy visits.

You asked the Plan to pre-approve 4 skilled physical therapy visits. You say that the services are necessary.
The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not
been met.

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 4 skilled physical therapy visits. Our
reviewer says that the services are not medically necessary. Our physician reviewer found you do not have
documented skilled nursing needs. You do not have documented skilled therapy needs. As such, the requested
home health skilled nursing and home health physical therapy 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 4 skilled physical therapy visits have not been met. Therefore, we decided that
the Plan does not have to pre-approve 4 skilled physical therapy visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the bilateral steroid injections provided on February 12, 2021, billed with diagnosis codes M18.11 and M18.12.

You asked the Plan to pay for the steroid injections. You say that the records support the two diagnosis codes billed. The Plan denied your request. The Plan says this claim was billed with two diagnosis codes for unilateral arthritis. This is not allowed per coding rules.

The Plan must follow Medicare rules. Medicare rules say that some diagnosis codes indicate laterality of a condition. If a condition is bilateral, reporting separate codes for left and right should be done when there is no bilateral diagnosis code for the condition.

In this case, the enrollee's condition is bilateral. The diagnosis codes reported are defined as Unilateral primary osteoarthritis of first carpometacarpal joint, right hand, and Unilateral primary osteoarthritis of first carpometacarpal joint, left hand, respectively. Code M18.0 exists which is for Bilateral primary osteoarthritis of first carpometacarpal joints. Since a bilateral code exists, it is not appropriate to report each side separately. As such, we find that the Medicare billing rules for the services at issue have not been met. Therefore, we decided that the Plan does not have to pay for the bilateral steroid injections provided on February 12, 2021, billed with diagnosis codes M18.11 and M18.12.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the complete upper denture (D5110) and lower partial
denture (D5212).
You asked the Plan to pre-approve the complete upper denture (D5110) and lower partial denture (D5212).
You say that you are having other medical issues and are not able to chew food. The Plan denied your request.
The Plan says coverage for CPT codes D5110 and D5212 is limited to 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, you also have a maximum benefit of
one complete upper denture (D5110) and one lower partial denture (D5212) every five plan years. The Plan
paid for the complete upper denture (D5110) provided on February 21, 2020 and paid for the lower partial
denture (D5212) provided on May 18, 2020, which exhausted your benefits. Therefore, we decided that the
Plan does not have to pre-approve the complete upper denture (D5110) and lower partial denture (D5212).