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

We decided that the Plan does not have to pre-approve a power scooter.
You asked the Plan to pre-approve a power scooter. You say that this is medically necessary. The Plan denied
your request. The Plan says that there is no clinical documentation and orders from your primary care physician
supporting the medical necessity of the electric scooter.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not
have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.
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 power scooter. Our reviewer says that
a power scooter is not medically reasonable and necessary for the enrollee. There is inconsistent documentation
with regard to your personal mobility deficit and your ability to participate in mobility related activities of daily
living such as toileting, feeding, grooming and bathing in customary locations within the home.
In one area of the office note of September 8, 2021, the provider indicates that the power mobility device will
not be used "all the time" and will be primarily for family "get togethers or outings." In another part of the note
the provider indicates you need assistance with ADL's due to neuropathy and weakness. There is
documentation that your mobility deficit cannot be helped by the use of a walker, cane or manual wheelchair
due to your level of instability due to neuropathy. There is documentation that you can safely operate a power
mobility device. There is no documentation that your home provides adequate access, maneuvering space and
surfaces for the operation of a power wheelchair. Our physician reviewer found that your condition does not
meet Medicare criteria for a power scooter.
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 power scooter have not been met. Therefore, we decided that the Plan does
not have to pre-approve a power scooter
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Botulinum injections.
You asked the Plan to pre-approve the requested services. You say that Xeomin is indicated for sialorrhea. The Plan denied your request. The Plan says that the service is not covered for the enrollee'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 requested services. Our physician reviewer found that Xeomin injections have been requested for the enrollee. She has a diagnosis of disturbances of salivary secretion. She has excessive salivation and dry lips. Chronic Sialorrhea is indicated for Xeomin. The requested use is not listed as not indicated, not supported or not recommended in any of the compendia. The documentation supports that the requested drug is safe and effective and otherwise reasonable and necessary for the enrollee in this case. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the requested services have been met. Therefore, we decided that the Plan has to pre-approve Botulinum injections.
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested admission is not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee was admitted for elective right knee replacement. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The documentation does not support
that the enrollee requires treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that you have acute pancreatitis with necrosis. You say that this has been an ongoing issue for 4 months now and have been in the hospital. The Plan denied your request. The Plan says the requested admission to an IRF is not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that your medical problems are stable and there are no complex nursing or rehabilitation needs. Our reviewer says that the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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 IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a percutaeneous electrical nerve stimulator (PENS) 
device. 
 
You asked the Plan to pre-approve a PENS device. You say that this request is medically reasonable and 
necessary. The Plan denied your request. The Plan says the clinical value and effectiveness have not been 
demonstrated in the peer-reviewed literature. 
 
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 PENS device. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee is a 55-year-old diagnosed with chronic pain syndrome with bilateral lower 
extremity pain, type II diabetes mellitus with diabetic polyneuropathy, unspecified neuralgia and neuritis, and a 
history of venous insufficiency. The clinical value and effectiveness of an auricular PENS device in the setting 
of chronic pain syndrome have not been demonstrated in the peer-reviewed literature. The review has 
determined that the requested PENS 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 a PENS device have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a percutaeneous electrical nerve stimulator (PENS) device.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Hereditary Cardiovascular Screening Panel provided on 
February 23, 2021. 
 
You asked the Plan to pay for the Hereditary Cardiovascular Screening Panel. You say that you would like 
reconsideration because this testing was medically necessary. The Plan denied your request. The Plan says 
genetic testing for cardiovascular risk factors has negligible benefit in the management of a member's health. 
 
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 pay for the Hereditary Cardiovascular Screening 
Panel. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found additionally, the Hereditary Cardiovascular Screening 
Panel is not a screening service that is covered by Medicare. 
 
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 Hereditary Cardiovascular Screening Panel have not been met. Therefore, 
we decided that the Plan does not have to pay for the Hereditary Cardiovascular Screening Panel provided on 
February 23, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Cosentyx pen.
You asked the Plan to pre-approve Cosentyx pen. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the requested drug is not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Cosentyx pen.
Benefits for Cosentyx pen may be available under Medicare Part D. Contact the Plan that administers Part D
benefits for further information concerning any benefits and appeal rights
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the knee scooter, crutch substitute, lower leg platform,
with or without wheels (E0118).
You asked the Plan to pre-approve the knee scooter. You say that you believe the Plan should cover your
scooter because it will be needed for about 6 weeks until you can walk again. The Plan denied your request.
The Plan says crutch substitutes such as knee scooters are excluded from Medicare coverage.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We looked at this the file, and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the knee scooter have not been met. Therefore, we decided that the Plan does not have to preapprove
the knee scooter, crutch substitute, lower leg platform, with or without wheels (E0118).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit with a specialist (99214) to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve an office visit with a specialist. You say that the provider operated the cataract of your left eye and advised to see you in a year or so. The Plan denied your request. The Plan says there are in-network providers available for these services.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The records provided for review do not show that the services at issue are urgent or emergent. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve an office visit with a specialist (99214) to be provided by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) services
You asked the Plan to pre-approve SNF services. You say that the patient has poor safety awareness and requires frequent cues to redirect her tasks which can cause harm. You say that she is no longer able to stay in the hospital and needs rehab. The Plan denied your request. The Plan says SNF services are 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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that there are no required skilled nursing services identified. Our reviewer says that the documentation does not support that it is medically reasonable and necessary to provide skilled therapy services on a daily basis in a skilled nursing facility on an inpatient 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 the SNF services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot insert (L3000).
You asked the Plan to pre-approve foot orthotics. You say that you require the inserts because one of your legs is shorter than the other. 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 pre-approve foot insert (L3000).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 11 home health skilled nursing visits. 
 
You asked the Plan to pre-approve 11 home health skilled nursing 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 11 home health skilled nursing visits. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found you do not have 
documented skilled nursing needs. As such, the requested, ongoing, home health skilled nursing services are 
not shown to be 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 11 home health skilled nursing visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve 11 home health skilled nursing visits.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a computed tomographic (CT) colonography.
You asked the Plan to pre-approve a CT colonography. 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. 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 CT colonography. Our reviewer says that the services are not medically necessary. Our physician reviewer found the requested service is excluded by rule from coverage. The elements of the coverage criteria are not satisfied. The requested service cannot be recommended. 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 CT colonography have not been met. Therefore, we decided that the Plan does not have to pre-approve a computed tomographic (CT) colonography.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for additional routine transportation trips. 
 
You asked the Plan to provide coverage for additional routine transportation trips. The Plan denied your 
request. The Plan says the Plan benefit coverage is for 24 one-way trips per calendar year and the 25th trip and 
beyond is not a covered benefit. The member has used 24 of the 24 trips and has 0 trips remaining in 2021. 
 
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 24 one-way trips per year.  

We looked at your request, the records in the case file, and the rules. The file shows you have used 24 one-way 
trips in 2021. 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 provide coverage for 
additional routine transportation trips.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the hereditary cardiovascular disease genetic testing provided on February 13, 2021.
You asked the Plan to pay for the genetic testing panel. You say that this is medically necessary and should be paid. The Plan denied your request. The Plan says this was billed with an invalid POS code.
The Plan must follow Medicare rules. Medicare rules say that for lab services, the POS code must reflect the location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory
directly. We looked at the file and Medicare rules. The file does not demonstrate that this sample was taken directly by the lab. As such, POS code 81 is not supported. Based on this information, we decided that Medicare rules for coverage of the genetic testing panel have not been met. Therefore, we decided that the Plan does not have to pay for the hereditary cardiovascular disease genetic testing provided on February 13, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional transportation trips.

You asked the Plan to pre-approve additional transportation trips. You say that you need transportation for your
medical appointments. The Plan denied your request. The Plan says you have utilized the maximum number of
transportation trips allowed per year.

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 24 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 transportation trips.
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 enrollee exceeds criteria for LTACH
admission. The Plan denied your request. The Plan says the enrollee does not meet criteria for LTACH level of
care.
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 that here is no evidence that the enrollee requires services that are not currently
available. As LTACHs and acute care hospitals (ACH) are licensed to provide the same level of care, there is
no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such
time no acute services are required.
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.