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

We decided that the Plan does not have to pre-approve a group 3 power wheelchair (K0861, E1007, E2311).

You asked the Plan to pre-approve the group 3 power wheelchair. You say that the power wheelchair is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met for this type of power wheelchair.

The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for enrollees who have a mobility limitation that is due to: 

1. A neurological condition; 

2. Myopathy; or 

3. Congenital skeletal deformity.

The file does not show that you have a mobility limitation that is due to a neurological condition, myopathy or congenital skeletal deformity. Therefore, we decided that the Plan does not have to pre-approve a group 3 power wheelchair (K0861, E1007, E2311).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient care provided from September 22, 2020 to
September 24, 2020.
You asked the Plan to pay for this claim. You say that this service should be covered by the Plan. The Plan
denied your request. The Plan says Medicare billing criteria are not met.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the
reported principal and secondary diagnosis codes. 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 this claim. Our reviewer says that Medicare billing criteria are not met. Our physician reviewer found
the documentation indicates that the enrollee presented with complaints of cough, shortness of breath and fever.
Blood cultures were negative. No documentation of persistent hypotension or hemodynamic instability. The
enrollee responded very quickly to treatment and required only 1 full day of hospital admission. While
encephalopathy is noted on the discharge summary, mental status was diagnosed as intermittent confusion,
"likely acute metabolic encephalopathy". Enrollee was documented to be alert and oriented. The review has
determined that the provided documentation did not support the billing of the ICD-10-CM codes, A41.9, sepsis
unspecified organism, and secondary diagnoses code assignments of R65.20, severe sepsis without septic
shock, andG93.41, metabolic encephalopathy.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay
for inpatient care provided from September 22, 2020 to September 24, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Contour Next test strips.

You asked the Plan to pre-approve Contour Next test strips. You say that the items 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. Medicare rules say that the information submitted by the supplier or provider must corroborate the documentation in the enrollee's medical records and confirm that Medicare coverage criteria have been met. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Contour Next test strips have not been met. Specifically, medical records were not provided. Without this documentation, medical necessity for a non-preferred brand is not able to be established. Therefore, we decided that the Plan does not have to pre-approve Contour Next test strips.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet joint injections for the enrollee.
You asked the Plan to pre-approve facet joint injections. You say that this treatment should be covered. The
Plan denied your request. The Plan says Medicare coverage criteria are not met.
The Plan must follow Medicare rules. Medicare only covers this treatment when 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 facet joint injections. Our reviewer says
that Medicare coverage criteria are not met. Our physician reviewer found the review indicates that the enrollee
is an 80-year-old male with chronic low back pain secondary to spinal stenosis and lumbar spondylosis. He has
been treated with medical therapy and epidural steroid injection therapy. He describes low back pain with
radiation to the right leg and has associated weakness. His provider has recommended facet joint injections.
Per the Medicare coverage criteria, radiculopathy and leg weakness are not considered part of the facet
syndrome. Medicare coverage criteria are not met. We looked at this physician's review, the file, and Medicare
rules. Based on this information, we decided that Medicare rules for coverage of facet joint injections have not
been met. Therefore, we decided that the Plan does not have to pre-approve facet joint injections for the
enrollee.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve laparoscopic sleeve gastrectomy services.
You asked the Plan to pre-approve the requested services. You say that the enrollee has never dropped below a BMI of 35. The Plan denied your request. The Plan says that the enrollee has been successful with medical treatment for obesity.
The Plan follows Medicare rules. Medicare rules say that bariatric surgery is only covered under certain medical indications. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the requested services. Our physician reviewer found that the enrollee has a body mass index of 37 kg/m2. Weight related co-morbid conditions include hypertension, fatty liver disease and pre-diabetes. She completed a comprehensive multidisciplinary evaluation that did not reveal any medical, dietary, behavioral or cardiopulmonary barrier to surgery. She has failed dietary efforts in the past. The records show that the coverage criteria for the requested services have been met. Therefore, the requested services are medically reasonable and 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 requested services have been met. Therefore, we decided that the Plan has to pre-approve laparoscopic sleeve gastrectomy services.
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 pay for the Personal Emergency Response System (PERS).
You asked the Plan to pay for the PERS. You say that you would like reconsideration because this device is medically necessary in case of an emergency. The Plan denied your request. The Plan says you do not meet criteria as you are not able to use this device.
The Plan must follow Medicare rules. Medicare rules say that telephone alert systems are denied as they are emergency communications systems and do not serve a diagnostic or therapeutic purpose. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the PERS have not been met. Therefore, we decided that the Plan does not have to pay for the Personal Emergency Response System (PERS).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve heel lifts.
You asked the Plan to pre-approve heel lifts. You say that heel lifts are medically necessary. The Plan denied your request. The Plan says heel lifts are 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. Heel lifts are not considered to be orthotics that fit this definition. The Plan follows these same rules. The records show you do not suffer from diabetic foot disease and you do not wear a leg brace and therefore do not meet criteria for orthotics in general. Although heel lifts may be appropriate for you, neither Medicare nor the Plan provides coverage for these items. Therefore, we decided that the Plan does not have to pre-approve heel lifts
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 based on the documentation provided the enrollee only requires short-term additional acute care services that can safely be administered at the current facility. The enrollee does not require services at the LTACH that are not already available at the current facility. 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric care from November 16, 2021, forward.
You asked the Plan to pre-approve inpatient psychiatric care from November 16, 2021, forward. You say that the services at issue are medically necessary. The Plan denied your request. The Plan says the services at issue are not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 inpatient psychiatric care from November 16, 2021, forward. Our reviewer says that the enrollee does not meet the criteria for acute inpatient mental health treatment beyond the date in question of November 16, 2021, forward. Our physician reviewer found the enrollee did not require inpatient mental health treatment beyond November 16, 2021, as she was not a danger to herself or others and did not have any delusions, auditory or visual hallucinations. It did not appear that active treatment was taking place beyond the date in question. It did not appear that the services for the dates in question were reasonably expected or medically necessary to improve the enrollee's condition or for the purpose of diagnosis. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient psychiatric care from November 16, 2021, forward have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from November 16, 2021, forward.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex procedure (22869).
You asked the Plan to pre-approve a Vertiflex procedure. You say that the requested treatment is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met because the requested treatment is experimental/investigational.
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 a Vertiflex procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that two learned orthopedic societies have published position papers that do NOT endorse the use of interspinous spacers for the treatment of spinal stenosis. 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 Vertiflex procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex procedure (22869).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve vision services with an out-of-network vision provider.
You asked the Plan to pre-approve the vision services. The Plan denied your request. The Plan says these services are available in-network.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when they are provided by an in-network provider. We looked at the file and the Plan's rules. The Plan has in-network vision specialists that can provide the requested vision services. Out-of-network vision care is not a covered benefit. Based on this information, we decided that the Plan's rules for coverage of the vision services have not been met. Therefore, we decided that the Plan does not have to pre-approve vision services with an out-of-network vision provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a rolling walker with seat for the enrollee.
You asked the Plan to pre-approve a rolling walker with seat. You say that a rolling walker with seat is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met.
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 and framed walker with wheels for use in the home. These items serve the same purpose as a rolling walker with seat. Medicare does not cover additional equipment for outside use or convenience of those caring for the enrollee. Therefore, we decided that the Plan does not have to pre-approve a rolling walker with seat for the enrollee
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
You asked the Plan to pre-approve a CGM. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says you do not meet criteria for the requested item.
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 a CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a third level of facet joint injections (64495).

You asked the Plan to pre-approve a third level of facet joint injections. You say that you need this due to severe back pain. The Plan denied your request. The Plan says a third level is not supported.

The Plan must follow Medicare rules. Medicare rules say that one to two levels of facet joint interventions, either unilateral or bilateral, are allowed per session per spine region. The need for a three or four-level procedure bilaterally may be considered under unique circumstances and with sufficient documentation of medical necessity on appeal. 

We looked at the file and Medicare rules. Two levels of facet joint injections were previously approved. The submitted medical records do not document unique circumstances necessitating a third level of injections. Based on this information, we decided that Medicare rules for coverage of a third level of facet joint injections have not been met. Therefore, we decided that the Plan does not have to pre-approve a third level of facet joint injections (64495).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a transit kit (K0108).
You asked the Plan to pre-approve a transit kit. You say that the enrollee needs this item. The Plan denied your request. The Plan says this is not covered.
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 item at issue in this appeal is for 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 transit kit (K0108).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional non-emergency, non-ambulance transportation services.
You asked the Plan to pre-approve additional trips. You say that you do not have any other means of transportation. The Plan denied your request. The Plan says 18 one-way trips are covered. The Plan says there are 2 remaining trips available at the time the appeal was received. The Plan also says that additional trips in excess of 18 one-way trips are not covered.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 18 one-way trips per year.
We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional non-emergency, non-ambulance transportation services.
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 based on the documentation provided the enrollee only requires short-term additional acute care services that can safely be administered at the current facility. The enrollee does not require services at the LTACH that are not already available at the current facility. 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.

You asked the Plan to pre-approve a shower chair. You say that you have seizures while showering. The Plan denied your request. The Plan says this item is not a covered benefit.

The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. 

While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable controller with harness and electronic connection for a power wheelchair (PWC).
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that an expandable controller and harness with electronic connection is included in standard power options. We looked at the file and Medicare rules. The file shows that the requested accessories are already included in the approved power wheelchair. 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 an expandable controller with harness and electronic connection for a power wheelchair (PWC).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an auricular stimulator.
You asked the Plan to pre-approve an auricular stimulator. The Plan denied your request. The Plan says this is not a covered service.
The Plan must follow Medicare rules. Medicare rules say that auricular peripheral nerve stimulation will be denied as non-covered. This service is not a covered Medicare benefit because acupuncture for auricular stimulation does not meet the definition of reasonable and necessary under Section 1862(a)(1) of the Act. We looked at the file and Medicare rules. Per LCA A55240, the requested auricular stimulator is not a covered service. Based on this information, we decided that Medicare rules for coverage of an auricular stimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve an auricular stimulator