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

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF care. You say that it is not safe for you to return home. The Plan 
denied your request. The Plan says you needs are 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 care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found the records do not show that you have skilled 
nursing needs. While you need skilled therapy services, you do not need them on a daily basis. You do not 
meet the severity of illness or intensity of service criteria for care on an inpatient basis in a skilled nursing 
facility 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 care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve percutaneous implantation of neurostimulator electrode 
(64555) and implantable neurostimulator (L8679).

You asked the Plan to pre-approve percutaneous implantation of neurostimulator electrode (64555) and 
implantable neurostimulator (L8679). You say that the goal is to help alleviate the patient's current pain and 
increase the patient's ability to participate in day-to-day activities, while reducing the need for use of opioid 
medications. You say that the patient has tried and failed conservative care and would be an excellent candidate 
for this procedure. The Plan denied your request. The Plan says auricular stimulation is not a Medicare covered 
service.

The Plan must follow Medicare rules. Medicare rules say that payment may be made for implanted peripheral 
nerve stimulators in which electrodes are surgically placed under the skin around a nerve. The rules also say 
that acupuncture is only covered when provided for low back pain when furnished by a licensed acupuncturist. 

We looked at the file and Medicare rules. We find that this device does not meet the Medicare definition for an 
implanted nerve stimulator because the device involves needles inserted around the nerves and not electrodes 
being surgically implanted. The Food and Drug Administration (FDA) clearances for devices of this type are as 
electro-acupuncture devices. Since acupuncture is not covered by Medicare for any condition when rendered 
through a device rather than by a licensed practitioner, we find that Medicare coverage criteria for this auricular 
stimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve percutaneous 
implantation of neurostimulator electrode (64555) and implantable neurostimulator (L8679).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for Evenity for the enrollee.
You asked the Plan to provide coverage for Evenity. You say that this drug is medically necessary. The Plan
denied your request. The Plan says Medicare coverage criteria are not met. We overturned the Plans
denial. The Plan requested a reopen and stated that we did not apply the correct criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for Evenity
(Romosozumab-aqqg). The medical records show the enrollee is a 75-year-old man with a diagnosis of
osteoporosis with an L1 vertebral compression fracture. Evenity is FDA-approved for the treatment of patients
with postmenopausal osteoporosis who are at high risk for fracture or have failed or been intolerant to other
therapy. The enrollee does not have postmenopausal osteoporosis. The compendia do not contain non-FDA
uses for this drug. Therefore, 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 Evenity have not been met. Therefore, we decided that the Plan does not have to
provide coverage for Evenity 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 Medicare criteria for the requested CGM.

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 with at least three daily injections and does not require frequent self-adjustment of insulin dosage based on the blood glucose testing results. 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two periodontal scalings and root planings of four or more teeth per quadrant (D4341 x2), two periodontal scalings and root planings of one to three teeth per quadrant (D4342 x2), four gingival irrigations (D4921 x4), and two drugs or medicaments dispensed in the office for home use (D9630 x2) provided on September 2, 2021.

You asked the Plan to pay for the scalings and planings, gingival irrigations, and drugs or medicaments. You say that these services were medically necessary, and you were not aware that you had limited benefits. The Plan denied your request. The Plan says these services are not covered under your benefit plan.

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, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the two periodontal scalings and root planings of four or more teeth per quadrant (D4341 x2), two periodontal scalings and root planings of one to three teeth per quadrant (D4342 x2), four gingival irrigations (D4921 x4), and two drugs or medicaments dispensed in the office for home use (D9630 x2) provided on September 2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a backpack holder and seat elevation feature for a power wheelchair.
You asked the Plan to pre-approve backpack holder and seat elevation feature. You say that you consider these features medically necessary. The Plan denied your request. The Plan says the denial of authorization for these components is correct, because a backpack holder is primarily for leisure or recreational activity and a seat elevation feature is not covered by Medicare.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The rules state that a power seat elevation feature is not covered because it is not primarily medical in nature.
The backpack holder at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Additionally, a power seat elevation is not covered by Medicare. Therefore, we decided that the Plan does not have to pre-approve a backpack holder and seat elevation feature for a power wheelchair.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of a Vertiflex device.
You asked the Plan to pre-approve the insertion of a Vertiflex device. You say that this is medically necessary. The Plan denied your request. The Plan says this has not been shown to be 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 the insertion of a Vertiflex device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertilfex device is experimental. More research is needed to show it is safe and effective. 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 insertion of a Vertiflex device have not been met. Therefore, we decided that the Plan does not have to pre-approve the insertion of a Vertiflex device.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care.
You asked the Plan to pre-approve continued SNF services. You say that SNF care continues to be medically necessary. The Plan denied your request. The Plan says SNF care is no longer medically reasonable and necessary for your condition.
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 continued SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you are an 87-year-old female with urinary tract infection and falls. In this case, there are no identifiable skilled nursing service needs and no identifiable skilled therapy service needs. Furthermore, you do not require skilled nursing or therapy services on a daily basis. In conclusion, you do not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 continued SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda.
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. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has recurrent non-small cell lung cancer (NSCLC) with metastases. Keytruda is Food and Drug Administration (FDA)-approved as single-agent treatment of metastatic NSCLC in patients with tumors with PD-L1 expression (TPS greater than or equal to 1 percent), as determined by an approved test, and with disease progression on or following platinum-containing chemotherapy. Patients with EGFR or ALK genomic tumor aberrations should have disease progression (on approved EGFR- or ALK-directed therapy) prior to receiving Keytruda. This enrollee has a PD-L1 of 0; therefore, Keytruda is 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 Keytruda.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xolair.
You asked the Plan to pre-approve the Xolair. You say that you would like reconsideration because the requested drug is medically necessary. The Plan denied your request. The Plan says the requested use of Xolair is not FDA approved for the member's condition.
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 the Xolair. Our reviewer says that the requested use of Xolair is not FDA-approved for the enrollee's diagnosis. Our physician reviewer found its use is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal.
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 Xolair have not been met. Therefore, we decided that the Plan does not have to pre-approve Xolair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve seat elevating system and its controller, upgraded controller, upgraded joystick, and seatbelt.
You asked the Plan to pre-approve seat elevating system and its controller, upgraded controller, upgraded joystick, and seatbelt. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested items are not medically necessary.
The Plan follows Medicare rules. Medicare rules say that power wheelchair accessories are only covered for certain 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 seat elevating system and its controller, upgraded controller, upgraded joystick, and seatbelt. Our reviewer says that the documentation does not support that the requested items are medically reasonable or necessary. Our physician reviewer found the enrollee has decreased strength in the left extremities and decreased endurance due to a stroke causing hemiparesis in April 2021. The enrollee is independent in eating. Right upper extremity strength is five out of five. The requested upgraded controller, upgraded joystick, and seatbelt are not medically necessary and exceed the enrollee's medical need. The requested items exceed the enrollee's medical need as there is no evidence that the enrollee requires an upgraded controller. A controller is included with the tilt and recline. The documentation does not support that the enrollee is unable to use a standard joystick therefore an upgraded joystick is not medically necessary. A seatbelt is already included in the wheelchair therefore the requested seatbelt is duplicative and 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 seat elevating system and its controller, upgraded controller, upgraded joystick, and seatbelt have not been met. Therefore, we decided that the Plan does not have to pre-approve seat elevating system and its controller, upgraded controller, upgraded joystick, and seatbelt
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion or replacement of a neurostimulator system for treatment of central sleep apnea.
You asked the Plan to pre-approve the insertion or replacement of a neurostimulator system for treatment of central sleep apnea. You say that you would like reconsideration because the requested procedure is medically necessary. The Plan denied your request. The Plan says the requested procedure is experimental.
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 insertion or replacement of a neurostimulator system for treatment of central sleep apnea.
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found for the enrollee's condition, the device is considered experimental and investigational as it is not widely used and generally accepted for the proposed use in nationally recognized peer reviewed medical literature. 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 insertion or replacement of a neurostimulator system for treatment of central sleep apnea have not been met. Therefore, we decided that the Plan does not have to pre-approve the insertion or replacement of a neurostimulator system for treatment of central sleep apnea.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lumbar medial branch blocks (MBBs).
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 MBBs are 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 enrollee has a history of cervical spondylosis and facet mediated pain with a chronic history of back pain for greater than 10 years. She has undergone a previous C3-C6 cervical fusion in 2003 and 2005. A history of anterior lumbar interbody fusion (ALIF) renders facet injections 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve lumbar medial branch blocks (MBBs).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for the partial lower denture (D5214) provided on August 4, 2021, by the out of network dentist.
You asked the Plan to pay an additional amount for the dental item. You say that the dental office advised they were in network. You say that you were not advised they were out of network until half of the work was completed. You say that the authorization for the work was approved. You also say that you feel you should not be responsible for paying all of this bill. The Plan denied your request. The Plan says there is a 50% coinsurance for partial dentures. The Plan also says that you will save more when you receive care from an in network dental providers.
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. We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental item have not been met.
Specifically, the file shows that the cost share was applied correctly. The record shows that the Plan paid 50% of the allowed amount, $625. Additionally, out of network providers may bill you for any amount greater than what the plan pays. Therefore, we decided that the Plan does not have to pay an additional amount for the partial lower denture (D5214) provided on August 4, 2021, by the out of network dentist.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Iv tubing extension set coded S1015 and the infection control supplies coded S8301 provided on June 10, 2021.
You asked the Plan to pay for the Iv tubing extension set and the infection control supplies. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable 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 CPT codes S1015 and S8301 are not supported in the medical record. Specifically, these codes have a status code of "I". A status code of I means that these codes are not valid for Medicare purposes. Medicare uses another code for reporting of, and payment of these services. Based on this information, we decided that Medicare rules for coverage of the Iv tubing extension set and the infection control supplies have
not been met. Therefore, we decided that the Plan does not have to pay for the Iv tubing extension set coded S1015 and the infection control supplies coded S8301 provided on June 10, 2021.