Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a pontic - porcelain/ceramic (D6245), guided tissue regeneration - resorbable barrier, per site (D4266), and bone graft at time of implant placement (D6104).

You asked the Plan to pay for a pontic, guided tissue regeneration and bone graft. You say that these services are necessary. The Plan denied your request. The Plan says these services are not covered under your benefits.

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 a pontic - porcelain/ceramic (D6245), guided tissue regeneration - resorbable barrier, per site (D4266), and bone graft at time of implant placement (D6104).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve intravenous moderate sedation (D9243 and D9239)
provided by a participating provider.
You asked the Plan to pre-approve intravenous moderate sedation. You say that this sedation is medically
necessary. The Plan denied your request. The Plan says the services requested are not covered benefits.
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 pre-approve
intravenous moderate sedation (D9243 and D9239) provided by a participating provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group three power wheelchair and accessories.
You asked the Plan to pre-approve a group three power wheelchair and accessories. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested items.
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 the enrollee has 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 three power wheelchair and accessories
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve intensity modulated radiation therapy (IMRT).

You asked the Plan to pre-approve intensity modulated radiation therapy (IMRT). You say that the tumor is irregularly shaped and in close proximity to critical structures. You also say that additional maneuvers to reduce the tumor/target volume margins have proven insufficient to produce an acceptable dose distribution. The Plan denied your request. The Plan says the IMRT is not medically 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 intensity modulated radiation therapy (IMRT). Our reviewer says that the requested intensity modulated radiation therapy (IMRT) is not considered medically reasonable and necessary in this case. Our physician reviewer found given that published studies have not shown a benefit of hippocampal avoidance whole-brain radiotherapy for small cell lung cancer, coupled with the progressive extracranial disease in this enrollee, the disputed treatment would not be in accordance with accepted standards of care. Therefore, the reviewer found that the requested treatment 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 intensity modulated radiation therapy (IMRT) have not been met. Specifically, the file shows that the requested treatment is not in accordance with accepted standards of care. Therefore, we decided that the Plan does not have to pre-approve intensity modulated radiation therapy (IMRT).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the MyoPro electronic arm brace.

You asked the Plan to pre-approve the Myopro device. You say that it is felt that this should be covered as the enrollee has been unable to achieve functional use of the left arm with maximal conventional therapies. The Plan denied your request. The Plan says there is not sufficient clinical evidence to support that this device is medically reasonable and necessary for this enrollee's condition.

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 Myopro device. Our reviewer says that the requested items are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is a male with a history of stroke and related left arm weakness. Based on the medical records provided, there is no documentation that the MyoPro electronic arm brace at issue in this case meets Medicare criteria for medically reasonable and necessary. The provided records document that the enrollee has a left shoulder subluxation which can be a contraindication to the use of the device. In addition, current clinical guidelines designate robotic therapy to be of "uncertain utility compared with dose-matched conventional upper limb exercise therapies" with unproven benefit in the home environment.

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 Myopro device have not been met. Therefore, we decided that the Plan does not have to pre-approve the MyoPro electronic arm brace.
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 the requested admission to an IRF is medically
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet
criteria.
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 continues to have a need for skilled therapy with ongoing safety
concerns and a potential for functional improvement however, the documentation doesn't support that the
enrollee would meet criteria for admission to an acute inpatient rehabilitation facility. There is no indication
that the enrollee would require skilled rehabilitation in an IRF, participating in rehab services 15 hours a week,
under the supervision of a physician with at least 3 visits weekly to regain or maintain her functional status.
The enrollee is ambulating short distances with minimal assistance. The enrollee can receive services 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve eight (8) additional speech therapy sessions.
You asked the Plan to pre-approve additional speech therapy sessions. You say that the requested speech therapy is medically necessary. The Plan denied your request. The Plan says the requested speech therapy does not meet criteria.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.
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 pre-approve speech therapy. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the enrollee has previously been treated with outpatient therapies and should be independent with a home exercise program. There is no documentation of a recent injury or decline in function. The enrollee is tolerating the current diet without complications. The additional therapy services are not an appropriate duration and frequency for treatment of the enrollee's medical condition. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of speech therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve eight (8) additional speech therapy sessions
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex Superion interspinous spacer device.
You asked the Plan to pre-approve the Vertiflex Superion interspinous spacer device. The Plan denied your
request. The Plan says this is not medically 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 the Vertiflex Superion interspinous
spacer device. Our reviewer says that the requested services are not considered medically reasonable and
necessary in this case. Our physician reviewer found that the Vertiflex device is experimental. More research is
needed to show safety and efficacy of this device.
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 Vertiflex Superion interspinous spacer device have not been met. Therefore,
we decided that the Plan does not have to pre-approve the Vertiflex Superion interspinous spacer device
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 the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.
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 continues to have a need for skilled therapy with ongoing safety concerns and a potential for functional improvement however, the documentation doesn't support that he would meet criteria for admission to an acute inpatient rehabilitation facility. There is no indication that the enrollee would require skilled rehabilitation in an IRF, participating in rehab services 15 hours a week, under the supervision of a physician with at least 3 visits weekly to regain or maintain his functional status. The enrollee does not have a prosthesis yet and can receive services 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a facet radiofrequency ablation procedure (64636, 64635).
You asked the Plan to pre-approve the facet radiofrequency ablation procedure. You say that the procedure is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that for each covered spinal region no more than two (2) radiofrequency sessions will be reimbursed per rolling 12 months. We looked at the file and Medicare rules. The record shows the enrollee has already had 2 radiofrequency sessions in the past 12 months. Based on this information, we decided that Medicare rules for coverage of the facet radiofrequency ablation procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve a facet radiofrequency ablation procedure (64636, 64635).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve side guards, impact guard, and a backpack for an ultralightweight wheelchair.
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 items are for use outside of the home and 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 items at issue in this appeal are for use outside of the home. Although these items 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 side guards, impact guard, and a backpack for an ultralightweight wheelchair
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve consultation and surgical procedure to be provided by an out-of-network (OON) interventional cardiologist.
You asked the Plan to pre-approve the OON interventional cardiology services. You say that you feel that you should be able to have this follow-up treatment provided by the same provider who placed your coronary artery grafts. The Plan denied your request. The Plan says there is no medical need for this procedure to be provided by an OON physician, or the physician who placed the grafts. There are in-network providers able to provide this service.
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 provider at issue in this case is not a network provider with the Plan.
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 OON interventional cardiology services. Our reviewer says that the documentation does not support the medical necessity for this service to be performed by an OON provider. Our physician reviewer found the enrollee is a male who underwent mitral valve replacement and coronary artery bypass graft surgery on 6/7/2021, with stable post-operative recovery. Follow up cardiac catheterization recently revealed a potential narrowing in one of the grafts, and the patient's physician recommended consultation with an out-of-network cardiologist who would be able to perform percutaneous coronary intervention (PCI), if needed. The clinical problem reflects possible need for PCI of one of the grafts placed in June 2021. This appears to be a straight-forward issue commonly encountered by experienced interventional cardiologists and should not require the services of a specific interventional cardiologist. In summary, there is insufficient documentation to support the medical necessity of consultation with an out-of-network cardiologist. 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 OON interventional cardiology services have not been met. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve the OON interventional cardiology services. Therefore, we decided that the Plan does not have to pre-approve consultation and surgical procedure to be provided by an out-of-network (OON) interventional cardiologist.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve three services performed by a qualified occupational therapist (G0152 x3).

You asked the Plan to pre-approve the services performed by a qualified occupational therapist. The Plan denied your request. The Plan says the records do not support the need for a skilled occupational therapist to make more home visits.

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 the services performed by a qualified occupational therapist. Our reviewer says that ongoing home health occupational therapy is not medically necessary or reasonable. Our physician reviewer found the enrollee does not have documented, ongoing home health occupational therapy needs. Our reviewer found that the enrollee is able to tend to activities of daily living with minimal assistance. Our physician reviewer also found that the enrollee has caregivers available to assist. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services performed by a qualified occupational therapist have not been met. Therefore, we decided that the Plan does not have to pre-approve three services performed by a qualified occupational therapist (G0152 x3).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an automatic blood pressure monitor.
You asked the Plan to pre-approve an automatic blood pressure monitor. You say that you need to check your blood pressure on a daily basis. The Plan denied your request. The Plan says you do not meet criteria for the requested item.
The Plan must follow Medicare rules. The rules say that Medicare covers home blood pressure monitors only for enrollees who are on home dialysis, or those who meet the criteria for white coat hypertension and require ABPM to confirm a diagnosis of hypertension. The records do not show that this monitor is requested in the setting of home dialysis services, or that this request is for evaluation of suspected white coat hypertension. Although monitoring blood pressure in the home may be appropriate in this case, neither Medicare nor the Plan provides coverage of this item in this situation. Therefore, we decided that the Plan does not have to pre-approve an automatic blood pressure monitor
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0676) provided November 11, 2020.

You asked the Plan to pay for a pneumatic compression device. You say that you provided the portable IPC device to the enrollee for home use after the enrollee received surgery at an ambulatory surgery center. The Plan denied your request. The Plan says pneumatic compression device is not covered by Medicare to prevent deep vein thrombosis during and/or following surgery.

The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement.

 We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0676) provided November 11, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a mastectomy sleeve.
You asked the Plan to pre-approve a mastectomy sleeve. You say that you have been wearing a sleeve since
your lumpectomy in December of 1997. You also say that the one you have is worn out. The Plan denied your
request. The Plan says the requested item is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that a mastectomy sleeve is denied as noncovered,
since it does not meet the definition of a prosthesis.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of a mastectomy sleeve have not been met. Therefore, we decided that the Plan does not have to pre-
approve a mastectomy sleeve.
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 continuous glucose monitor. You say that the continuous glucose monitor is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
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. Based on this information, we decided that Medicare rules for coverage of the continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor.