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

We decided that the Plan does not have to reimburse you for the wheelchair purchased on March 22, 2021.
You asked the Plan to reimburse you for the standard wheelchair with elevating seat. You say that the wheelchair was medically necessary immediately, so you bought one. The Plan denied your request. The Plan says a wheelchair is a capped rental item therefore no payment can be made.
The Plan must follow Medicare rules. Medicare rules say that a wheelchair must be rented.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the standard wheelchair with elevating seat have not been met. Therefore, we decided that the Plan does not have to reimburse you for the wheelchair purchased on March 22, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Computed tomographic (CT) colonography (74261).
You asked the Plan to pre-approve the CT colonography. You say that you are requesting a standard appeal for the denial of a virtual colonoscopy. The Plan denied your request. The Plan says the medical records do not support that the Medicare criteria has been met.
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 CT colonography. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found Medicare guidelines requires certain criteria be met to cover CPT 74261. The documentation submitted does not meet the criteria. The records show that on June 21, 2018, a Colonoscopy was performed and a "repeat colonoscopy in 3 years for surveillance based on pathology results". There is no additional documentation to support medical necessity. 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 CT colonography have not been met. Therefore, we decided that the Plan does not have to pre-approve Computed tomographic (CT) colonography (74261).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the coronavirus vaccine administration provided April 29, 2021.
You asked the Plan to pay for the coronavirus vaccine administration. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says this claim should be submitted to the MAC for the enrollee's jurisdiction.
The Plan must follow Medicare rules. Medicare rules say that Original Medicare is responsible for payment for the coronavirus vaccine. We looked at the file and Medicare rules. Pursuant to CMS guidance Medicare payment for coronavirus
vaccinations administered during calendar years 2020 and 2021 to MA beneficiaries will be made through the Medicare Fee for Service program. Based on this information, we decided that Medicare rules for coverage of the coronavirus vaccine administration have not been met. Therefore, we decided that the Plan does not have to pay for the coronavirus vaccine administration provided April 29, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the spinal simplicity interspinous-interlaminar fusion device (Minuteman device) (CPT code 22612), for the enrollee.
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your request. The Plan says the Medicare criteria for reasonable and necessary are not met because use of this device as a stand-alone procedure has not been shown to be safe and effective in long term studies. The Plan states this device is not approved for use in a stand-alone procedure as requested by the enrollee's pain practitioner provider.
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 items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found current evidence based medical guideline and peer reviewed literature do not fully support the interspinous fusion device procedure over the 'gold standard' of lumbar fusion. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of this device for this enrollee's medical condition as discussed. This enrollee has multiple degrees of spinal stenosis, many not at Food and Drug Administration (FDA) indicated levels of "moderate" spinal stenosis (including the planned level of implantation L4-L5.)
FDA contraindications include spinal instability, scoliosis, obesity, and osteoporosis, and have not been
adequately addressed in the medical records. There is no discussion of spinal instability on flexion/extension
films. There is no discussion of scoliosis of the lumbar spine. There is no discussion indicating that a DEXA
scan has demonstrated the lack of significant osteoporosis in this patient. In addition, fusion indications within
guidelines/literature for (existing or potential intraoperative) instability have not been documented and/or met
in this case. In addition, there are multiple alternate pain generators plausibly significantly contributing to the
clinical condition that have not been fully documented as having been excluded and/or ruled out. There is no
compelling rationale presented or extenuating circumstances noted to support the medical necessity of this
request as an exception to guidelines. Therefore, the request for spinal simplicity interspinous-interlaminar
fusion device (Minuteman device) (CPT code 22612) at levels L4-5 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 the services have not been met. Therefore, we decided that the Plan does not
have to pre-approve the spinal simplicity interspinous-interlaminar fusion device (Minuteman device) (CPT
code 22612), for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) (K0553), provided on February 11, 2021.
You asked the Plan to pay for the CGM supplies. You say that the service was medically necessary. The Plan denied your request. The Plan says the enrollee does not use insulin multiple times a day.
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 and have had an in-person visit with their treating physician to assesses
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
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of
the CGM supplies have not been met. Therefore, we decided that the Plan does not have to pay for the
continuous glucose monitor (CGM) (K0553), provided on February 11, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for foot orthotics provided on July 7, 2021.
You asked the Plan to pay for foot orthotics. You say that you have severe scoliosis, stenosis and cannot walk without orthopedic inserts. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pay for foot orthotics provided on July 7, 2021.
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 admission to an LTACH is medically necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically necessary.
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 continues to receive acute care services and these have not been denied. The medical record does not indicate that the enrollee requires services that she is not currently receiving but that would be available at the LTACH 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you have stabilized medically and are ready for discharge from the hospital. You do not require skilled nursing and/or skilled therapy services on a daily basis. You are medically stable and can receive further rehabilitation services at a lower level of care. Although further rehabilitation 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 SNF. You do not have any parental medication; daily complex wound care or nutrition given via a feeding tube. You are medically stable without any acute exacerbations of chronic medical problems. Your physical function is at or near your new baseline and you can receive services at a lower level of care. Admission to a SNF for inpatient skilled rehabilitation services is 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a dorsal root ganglion (DRG) stimulator.
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 an electrical nerve stimulator is covered when specific criteria are met. 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 records show that you have chronic low back and buttock pain. You have received psychological clearance for a DRG stimulator. There is no prior history of surgery, nerve block injections, or epidural steroid injections. The criteria for coverage of the DRG stimulator are not met and the services are therefore not reasonable or medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a dorsal root ganglion (DRG) stimulator.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan does not have to pre-approve a chest computed tomography angiography (CTA) (71275).
You asked the Plan to pre-approve a chest CTA. You say that you are requesting a complete CTA examination to figure out the best course of treatment. Medical records are attached. The Plan denied your request. The Plan says the records do not meet chest CT angiography guidelines and the procedure is 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 a chest CTA. Our reviewer says that the requested items/services is considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee's previous CTA of the chest demonstrated an area of irregular plaque in the thoracic aorta. In a patient with both abdominal and mesenteric arterial aneurysms as well as the development of a pseudoaneurysm in the right femoral artery, it would be reasonable if the patient's surgeon requested that a CTA of the chest be obtained at the time of the ABD and Pelvis to be sure there were no degenerative changes occurring in the thoracic aorta as well. The documentation supports the medical necessity of the study in question. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of a chest CTA have been met. Therefore, we decided that the Plan does not have to pre-approve a chest computed tomography angiography (CTA) (71275).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve negative pressure wound therapy (NPWT) electrical
pump (E2402).
You asked the Plan to pre-approve negative pressure wound therapy electrical pump. You say that the wounds
are healing but not yet completely healed. In paralyzed areas it takes longer to heal. Blood flow is slowed
down. The Plan denied your request. The Plan says the requested service is not medically necessary as the
request is for over 4 months of treatment.
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 negative pressure wound therapy
electrical pump. Our reviewer says that the requested items/services are not considered medically reasonable
and necessary in this case. Our physician reviewer found the enrollee has chronic wounds for which negative
pressure wound therapy had been used for over 4 months already. Wounds are reported to be healing but not
completely healed. Negative pressure wound therapy device was requested for an extension of 4 months. Due
to the excessively long duration for this request, the negative pressure wound therapy device request of an
additional 4 months does not meet the Medicare coverage.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of negative pressure wound therapy electrical pump have not been met. Therefore,
we decided that the Plan does not have to pre-approve negative pressure wound therapy (NPWT) electrical
pump (E2402).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office services (99386) provided April 1, 2021.
You asked the Plan to pay for the office services. You say that these services were medically necessary for your condition. The Plan denied your request. The Plan says these services are not covered by Medicare.
The Plan must follow Medicare rules. The rules say that Medicare does not cover naturopathic services. The services at issue in this appeal are naturopathic services. Therefore, we decided that the Plan does not have to pay for the office services (99386) provided April 1, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on September 22, 2020.
You asked the Plan to pay for the services provided. You say that this testing is used for clinical purposes. The
Plan denied your request. The Plan says the billed codes cannot be verified.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate code.
We looked at the file and the rules. The billed claim shows a place of service as an office. However, the records
indicate the enrollee was in a skilled nursing facility at the time the specimen was obtained. Based on this
information, we decided that Medicare rules for coverage of the services provided have not been met.
Therefore, we decided that the Plan does not have to pay for the lab services provided on September 22, 2020.
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 the SNF services. You say that the enrollee is very confused and cannot ambulate 180 feet without breaks. You say that the enrollee is not ready to live independently. You say that the enrollee cannot walk by himself. The Plan denied your request. The Plan says the enrollee has no IVs or complex wound care. The Plan says that the SNF level of care is not medically necessary. The Plan says that the enrollee does not require daily skilled services on an inpatient basis at the SNF level of care.
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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there is no documentation that the enrollee requires skilled nursing services. The medical records show that the enrollee does required skilled therapy services, but that they are not required on a daily basis. The enrollee does not require the services on an inpatient basis, only in a skilled nursing facility setting. Services in a long-term care facility on a part time basis appear appropriate 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 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan
denied your request. The Plan says that you have been discharged from physical therapy and occupational
therapy.
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 reviewer says that
daily skilled services are not necessary. Our physician reviewer found that your condition does not meet
Medicare criteria for continued SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not
have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the hereditary cardiovascular screening panel provided on February 22, 2021.
You asked the Plan to pay for the testing services. You say that the services were medically necessary. The Plan denied your request. The Plan says this testing is not a Medicare covered screening service.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. We looked at the file and the rules. The records provided do not indicate the enrollees treating physician would use the results for a specific medical problem or treatment strategy. The test at issue in this appeal was requested for screening purposes. Medicare does not cover this testing for screening purposes. Therefore, we decided that the Plan does not have to pay for the hereditary cardiovascular screening panel provided on February 22, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve percutaneous peripheral nerve stimulation (CPT code 64555), for the enrollee.
You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan denied your request. The Plan says that non-implanted peripheral nerve stimulators are not covered by Medicare.
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 service. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found a request for percutaneous peripheral nerve stimulation for up to sixty (60) days was made. Based on the NCD for Medicare coverage, although this request is not for an implantable nerve stimulator device, a trial of a peripheral device is reasonable to determine if an implantable device would be reasonable and effective. Therefore, the medical records provided meet the requirements listed in the NCD for Medicare coverage. 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 service have been met. Therefore, we decided that the Plan has to pre-approve percutaneous peripheral nerve stimulation (CPT code 64555), for the enrollee.