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

We decided that the Plan does not have to pre-approve a continuous glucose monitor.
You asked the Plan to pre-approve the requested device. The Plan denied your request. The Plan says the
enrollee does not meet criteria.
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 does not indicate that the enrollee uses insulin
with at least three daily injections, or requires 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 the requested
device have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous
glucose monitor.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genicular nerve block (GNB) to the right knee.
You asked the Plan to pre-approve GNB to the right knee. You say that the records provided support the need for the requested injection services. The Plan denied your request. The Plan says the requested injection services are not medically reasonable and necessary.
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 GNB to the right knee. Our reviewer says that GNB services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has chronic right knee pain and had a right total knee arthroplasty. The enrollee has been treated with home exercises, physical therapy, nonsteroidal anti-inflammatory drugs (NSAIDs), heat/ice, and medication management. Genicular nerve blocks and genicular nerve radiofrequency ablation are considered investigational and not medically necessary for the treatment of chronic knee pain, including, but not limited to degenerative joint disease; osteoarthritis of the knee; as a treatment prior to knee replacement; as a treatment following knee replacement; or as a treatment for individuals who are not candidates for knee replacement surgery.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of GNB to the right knee have not been met. Therefore, we decided that the Plan does not have to pre-approve genicular nerve block (GNB) to the right knee
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 for the enrollee.
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan
denied your request. The Plan says that the enrollee's ongoing skilled therapy and nursing needs can be
provided at a lower level of care.
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. The
complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient
stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for revascularization
surgery of lower extremity. The enrollee's medical problems are stable. There are no complex nursing or
rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical
therapy or occupational therapy, and an intensive rehabilitation therapy program. While the patient has a need
for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation
program. There is not a reasonable expectation that this patient will be able to fully participate in and benefit
from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the
enrollee's condition does not meet Medicare criteria for IRF 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 for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable ventilator.
You asked the Plan to pre-approve a portable ventilator. You say that the clinical documentation provided
supports non-invasive ventilation therapy. The Plan denied your request. The Plan says a home mechanical
ventilator set in average volume-assured pressure support (AVAPS) mode that could be delivered by bi-level
positive airway pressure (BiPAP) is not covered.
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory
failure due to COPD.
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 portable ventilator. Our reviewer says
that the criteria for coverage have not been met. Our physician reviewer found the record indicates that the
enrollee has chronic obstructive pulmonary disease and obstructive pulmonary disease. The record indicates
that the enrollee uses continuous positive airway pressure (CPAP) with supplemental oxygen at home. An
arterial blood gas revealed a partial pressure of oxygen (paO2) of 70 and a partial pressure of carbon dioxide
(paCOO2) of 47. The provided primary source documentation does not contain sufficient detailed information
in the medical record to justify the treatment selected. The enrollee could be treated with a BiPAP machine
with AVAPS capability. The Plan has indicated such a device would be considered. The elements of the
coverage criteria are not satisfied.
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 portable ventilator have not been met. Therefore, we decided that the Plan
does not have to pre-approve a portable ventilator.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient mental health facility for the enrollee.
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says treatment can be provided with outpatient care or other services.
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 the admission.
Our reviewer says that the requested admission is not medically reasonable or necessary. Our physician reviewer found it is not expected that this enrollee would improve in a reasonable period of time as he does not have dangerousness to self or others, auditory or visual hallucinations, delusions and was not showing any aggressive behavioral issues. The health plan's denial of inpatient psychiatric services appears appropriate. 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 admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to an inpatient mental health facility for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve paravertebral facet joint injections for the enrollee.

You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says there is a positive straight leg raise on the right, showing that the problem may be discogenic and not facet.

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 injection. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found it appears that there may be discogenic pain as a component of this enrollee's problem. The criteria requires that there not be any other pain generators. 

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 injection have not been met. Therefore, we decided that the Plan does not have to pre-approve paravertebral facet joint injections for the enrollee
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. The Plan denied your request. The Plan says the enrollee can continue to get care in the current hospital setting.
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 physician reviewer found that in this case, the enrollee was admitted to the acute care hospital for aspiration pneumonia. The record indicates that the enrollee remains ventilated and may require initiation of dialysis. He is not medically stable. He continues to receive acute care services, and these have not been denied. The medical record does not indicate that the enrollee requires services that he is not currently receiving but that would be available at the LTACH facility. Therefore, the requested services are not considered 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 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 admission to a skilled nursing facility (SNF) for the enrollee.
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says needs may be met with part-time skilled services in long-term care, if approved by the plan.
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 admission. Our reviewer says that the requested admission is not medically reasonable or necessary. Our physician reviewer found based on the medical records provided, there is no documentation that the patient requires skilled nursing services or skilled therapy services, i.e., the specialized skill, knowledge and judgment of a skilled professional nurse or a qualified therapist are not required to safely and effectively provide medically necessary and reasonable treatment. Daily skilled services are not required. 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 may be 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 admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
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 The Plan denied your request. The Plan says the intensity of an inpatient rehabilitation facility 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 physician reviewer found that you were admitted to the acute care hospital for weakness, stroke, and hypertension. Your medical problems are stable. While you have a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable ventilator.
You asked the Plan to pre-approve a portable ventilator. You say that the records provided support the need for a portable ventilator. The Plan denied your request. The Plan says a home mechanical ventilator set in TTV-VAPS mode that could be delivered by Bi-level positive airway pressure (BiPAP).
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. 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 portable ventilator. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found a home ventilator is not medically necessary. The enrollee has severe chronic obstructive pulmonary disease (COPD) with mild carbon dioxide (CO2) retention. The records do not support diagnoses of neuromuscular disease or thoracic restrictive
disease. BiPAP has not been tried. Medicare does not cover a home ventilator when used as BiPAP. Certain
BiPAP devices can provide the average volume-assured pressure support (AVAPS) mode of support. Battery
backup is not necessary because the enrollee is not dependent on continuous ventilator support.
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 portable ventilator have not been met. Therefore, we decided that the Plan
does not have to pre-approve a portable ventilator.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone marrow aspirate for the enrollee.
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the clinical value and effectiveness of bone marrow aspirate in the setting of spinal fusion surgery has 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 these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Bone marrow aspirate remains experimental for use is spinal surgery. More research is needed to show safety and efficacy. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve bone marrow aspirate for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve electronic connection between wheelchair controller and
two or more power seating system motors, including all related electronics, indicator feature, mechanical
function selection switch, and fixed mounting hardware (CPT code E2311) and addition to power seating
system, center mount power elevating leg rest/platform, complete system, any type, each (CPT code E1012),
for the enrollee.
You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your
request. The Plan says the notes do not show that the enrollee has a condition for which power leg lifts are
needed.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we
decided that Medicare rules for coverage of the DME have not been met. The notes do not show that the
enrollee has a medical need for the power leg lifts. The upgraded electronics are not medically necessary. They
are necessary when there is a medical need to control two or more power options though the joystick. The notes
do not show a medical need to control the two or more power options through the joystick.
Therefore, we decided that the Plan does not have to pre-approve electronic connection between wheelchair
controller and two or more power seating system motors, including all related electronics, indicator feature,
mechanical function selection switch, and fixed mounting hardware (CPT code E2311) and addition to power
seating system, center mount power elevating leg rest/platform, complete system, any type, each (CPT code
E1012), for the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the abdominal ultrasound (76705) provided on June 2, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the abdominal ultrasound. You say that this claim should be covered at the in-network rate. The Plan denied your request. The Plan says these services were provided out-of-network. The Plan only covers out-of-network care in limited circumstances. No demographic update or plan change request was received prior to the date of service. The previous demographic change request was in March 2020 confirming a different state of residence than the state where services were provided in this case. Therefore, the network status of this claim is correct.
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 pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the abdominal ultrasound (76705) provided on June 2, 2021 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a tie down loop represented by code K0108 and a power
seat elevation system represented by code E2300.
You asked the Plan to pre-approve codes K0108 and E2300. You say that you need the items in dispute. The
Plan denied your request. The Plan says the requested tie down kit is not covered because it is not used to take
care of a medical need. The Plan says that the power seat elevation system is statutorily non-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.
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 for codes K0108 and E2300. Our reviewer says that
the criteria for coverage have not been met. Our physician reviewer found that the tie down loop is used to
facilitate travel in a vehicle and does not serve a primary medical need. It is not considered medically
necessary. The power seat elevation system is non-covered by Medicare because Medicare has stated that it is
not primarily medical in nature.
We looked at this physician's review, the file, and Medicare rules. The items at issue in this appeal do not serve
a purpose that is primarily medical in nature. Therefore, we decided that the Plan does not have to pre-approve
a tie down loop represented by code K0108 and a power seat elevation system represented by code E2300.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the set-up portable x-ray equipment (Q0092) and radiologic
examination, chest (71046) provided on May 11, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the portable x-ray services. You say that your services are treated as an
emergency service in the nursing home and home health setting. Insurance carriers do not require portable x-
ray suppliers across the country to get prior authorizations. The Plan denied your request. The Plan says
enrollee's must receive their medical services from an in-network provider with the exception being urgent or
emergent services. Non-emergent services with non-contracted providers require prior authorization before
services being rendered.
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 pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan had network providers
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for the set-up portable x-ray equipment (Q0092) and
radiologic examination, chest (71046) provided on May 11, 2021 by an out-of-network (OON) provider.