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

We decided that the Plan does not have to pre-approve compression stockings identified with code A6531.
You asked the Plan to pre-approve the compression stockings. You say that compression stockings are medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6531 are covered for open venous stasis ulcers. The medical records show you are being treated for a rash due to fluid buildup in your legs, which is a cardiovascular issue. Although this item may be appropriate for your use, you do not have a medical condition for which is it covered. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6531.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the cone beam CT capture and re-treatment of previous root canal therapy.
You asked the Plan to pre-approve the cone beam CT capture and re-treatment of previous root canal therapy. You say that the tooth was still infected and needed a re-treatment. You say that this should be covered. The Plan denied your request. The Plan says a root canal or root canal re-treatment is only covered once per tooth per lifetime and the cone beam CT capture is not a covered benefit.
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, you also have a maximum benefit of one root canal or root canal re-treatment per tooth. The Plan paid for the root canal for this tooth provided on March 22, 2021, which exhausted your benefit. The cone beam CT capture remains denied as a non-covered benefit. Therefore, we decided that the Plan does not have to pre-approve the cone beam CT capture and re-treatment of previous root canal therapy
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 the services can be received while remaining in the hospital.
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 there are no identifiable skilled nursing service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee does 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 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: 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. You say that additional routine transportation trips are necessary. The Plan denied your request. The Plan says once this benefit is exhausted it cannot be extended.
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 30 one-way trips per year. Once this benefit is exhausted it cannot be extended. Therefore, we decided that the Plan does not have to provide coverage for additional routine transportation trips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0676).
You asked the Plan to pre-approve a pneumatic compression device. You say that you are appealing the denial of the pneumatic compression pumps that you will need for your surgery. The Plan denied your request. The Plan says pneumatic compression device for the prevention of venous thrombosis is not a covered benefit.
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 pre-approve a pneumatic compression device (E0676).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair and accessories for the enrollee.
You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied your request. The Plan says Medicare does not cover durable medical equipment (DME) in a skilled nursing facility (SNF).
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home. Records show that the wheelchair is being requested for use in a SNF or hospital. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair and accessories for the enrollee
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM)
system and supplies.
You asked the Plan to pre-approve the CGM system and supplies. You say that the items in dispute are
medically necessary. The Plan denied your request. The Plan says the criteria for coverage have 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 perform blood glucose testing at least four times per
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based
on the blood glucose testing results and have had an in-person visit with their treating physician to assesses
adherence to their CGM regimen and diabetes treatment plan.
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of
the CGM system and supplies have not been met. Therefore, we decided that the Plan does not have to preapprove
a Freestyle Libre continuous glucose monitor (CGM) system and supplies.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a surgical tooth extraction (D7210) with deep
sedation/general anesthesia (D9222, D9223).
You asked the Plan to pre-approve the extraction and anesthesia. You say that these services are medically
necessary to treat a broken tooth. The Plan denied your request. The Plan says these services are not covered by
your dental benefit.
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 a
surgical tooth extraction (D7210) with deep sedation/general anesthesia (D9222, D9223).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone graft at time of implant placement (D6104) and surgical access to an implant body (second stage implant surgery) (D6011) for teeth 8 and 9.

You asked the Plan to pre-approve bone graft at time of implant placement and surgical access to implant body. You say that the services are necessary, and you cannot afford the cost. The Plan denied your request. The Plan says these services are not covered under your 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 pre-approve bone graft at time of implant placement (D6104) and surgical access to an implant body (second stage implant surgery) (D6011) for teeth 8 and 9.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre device and supplies (K0554, K0553).
You asked the Plan to pre-approve a Freestyle Libre device and supplies. You say that the requested item is a medical necessity for you. The Plan denied your request. The Plan says rules for therapeutic continuous glucose monitors have 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 you do 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 Freestyle Libre device and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre device and supplies (K0554, K0553).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the compression stockings identified with code A6549 that were issued on July 14, 2021.
You asked the Plan to pay for the compression stockings. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are noncovered because they do not meet the statutory definition of a surgical dressing. Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for the compression stockings identified with code A6549 that were issued on July 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a partial upper denture with flexible base (D5225).
You asked the Plan to pre-approve the dental item. You say that this denture is medically necessary. You say that the dental office only does flexible base partials. You also say that you are having more teeth extracted and a crown which will require you to have this partial. The Plan denied your request. The Plan says partial upper denture with flexible base is not listed as a covered service.
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 partial upper denture with flexible base is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a partial upper denture with flexible base (D5225).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says the services can be received in a different setting, for example, home with home health, in residential care, or home with close follow-up with the doctor.
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 there are no identifiable skilled nursing or skilled therapy service needs. You do not require skilled nursing or therapy services on a daily basis. 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 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).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve pneumatic compression devices (E0652, E0667).
You asked the Plan to pre-approve pneumatic compression devices. You say that the requested items are a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment for pneumatic compression devices have not been met.
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required. 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, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. The item coded E0667 is not separately payable when the base item is not covered. Therefore, we decided that the Plan does not have to pre-approve pneumatic compression devices (E0652, E0667).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve disposable gloves.

You asked the Plan to pre-approve disposable gloves. You say that disposable gloves are medically necessary. The Plan denied your request. The Plan says disposable gloves are not covered by Medicare.

The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. While disposable gloves may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve disposable gloves.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve office visits to be rendered by an out-of-network (OON)
provider.
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the
Plan's denial. The Plan denied your request. The Plan says there are in-network providers available to render
the requested 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.
You are not a network provider with the Plan. The Plan has network providers available who can provide the
services at issue in this appeal. We found no exception that would require the Plan to pre-approve these
services. Therefore, we decided that the Plan does not have to pre-approve office visits to be rendered by an
out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a wireless capsule endoscopy.
You asked the Plan to pre-approve a wireless capsule endoscopy. You say that a wireless capsule endoscopy is medically necessary. The Plan denied your request. The Plan says under Medicare guidelines, your request is not medically necessary because the records show the enrollee has not had a recent upper and lower endoscopy.
The Plan follows Medicare rules. Medicare rules say that indications for wireless capsule endoscopy: For investigating suspected small intestinal bleeding in persons with objective evidence of recurrent, obscure GI bleeding (e.g., persistent or recurrent iron-deficiency anemia and/or persistent or recurrent positive fecal occult blood test (FOBT), or visible bleeding) who have had upper and lower GI endoscopies within the past 12 months (esophagogastroduodenoscopy (EGD) and colonoscopy) that have failed to identify a bleeding source. 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 wireless capsule endoscopy. Our reviewer says that a wireless capsule endoscopy is not medically necessary. Our physician reviewer found Specifically, the enrollee is neither anemic, nor has she undergone EGD and colonoscopy within the last 12 months that have failed to identify GI bleeding. In fact, the enrollee is overdue for scheduled endoscopic surveillance of her known Barrett's esophagus. 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 wireless capsule endoscopy have not been met. Therefore, we decided that the Plan does not have to pre-approve a wireless capsule endoscopy.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pain pump trial.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that infusion pump implantation is contraindicated with other implanted programmable devices. We looked at the file and Medicare rules. The file shows that the enrollee has a contraindicated spinal cord stimulator implant. 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 a pain pump trial.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a total electric hospital bed.
You asked the Plan to pre-approve a total electric hospital bed. You say that a total electric hospital bed is
medically necessary. The Plan denied your request. The Plan says a total electric hospital bed is not covered by
Medicare.
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital
bed.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital services with diagnosis related group (DRG) 871 provided from June 7, 2020 to June 11, 2020.
You asked the Plan to pay for the inpatient hospital services with DRG 871. You say that the medical records support the billing of principal diagnosis code A41.9 and secondary diagnosis code G93.41 with DRG 871. The Plan denied your request. The Plan says the medical records do not support the billing of principal diagnosis code A41.9 and secondary diagnosis code G93.41 with DRG 871.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes. In this case, you billed the inpatient services provided with principal diagnosis code A41.9 and secondary diagnosis code G93.41. 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 inpatient hospital services with DRG 871. Our reviewer says that the medical records do not support the billing of principal diagnosis code A41.9 and secondary diagnosis code G93.41 with DRG 871. Our physician reviewer found the review indicates that the enrollee presented to the emergency department on June 7, 2020 with weakness. The evaluation including physical exam, laboratory studies and chest x-ray revealed probable bilateral pneumonia with tachycardia and creatinine increased to 3.67. He was treated with IV fluids and IV antibiotics. There was no clinical or laboratory evidence of sepsis. He was noted to have baseline cognitive issues but was described as alert and oriented x3. There was no evidence of encephalopathy. The review has determined that the records did not support the billing of DRG 871 with principal diagnosis code A41.9 and secondary diagnosis code G93.41. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for the inpatient hospital services with diagnosis related group (DRG) 871 provided from June 7, 2020 to June 11, 2020.