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

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and segmental pneumatic appliance (E0667).
You asked the Plan to pre-approve a pneumatic compression device and appliance. You say that you request the approval of the most appropriate device based on the enrollee's condition. The Plan denied your request. The Plan says the enrollee does not meet the LCD criteria for an advanced lymphedema pump as there is no failed four-week trial of a basic pneumatic compression device of either E0650 or E0651.
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. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and segmental pneumatic appliance (E0667).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the breast prosthesis, mastectomy sleeve (L8010).
You asked the Plan to pre-approve the mastectomy sleeve. You say that you have been medically required to
wear a support sleeve since 2008. Following your chemo and radiation treatment, the sleeve was required due
to lymphedema. You have been getting new ones each year since 2008. The Plan denied your request. The Plan
says this item is not covered by Medicare or the Plan.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the mastectomy sleeve have not been met. Therefore, we decided that the Plan does not have to
pre-approve the breast prosthesis, mastectomy sleeve (L8010).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hydroxyzine pamoate capsules.
You asked the Plan to pre-approve self-administered drug. You say that the enrollee needs this drug as a bridge to improvement in her condition. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because this drug is not covered by Medicare Part B and the Plan does not administer the enrollee's Medicare Part D prescription drug benefits.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered 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 hydroxyzine pamoate capsules.
Benefits for self-administered drug 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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve proton treatment delivery, intermediate for the enrollee.  You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the records do not show enrollment in a clinical trial.  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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee agreed to consent to a registry study. This registry study enrolls any patient receiving proton therapy for any disease, which should not be sufficient for claiming medical necessity, as any and all patients treated with radiation therapy could then be considered for proton therapy without consideration for true need of this service. Notably, registry studies are not clinical trials or studies, and have a much less rigorous development process. A tumor registry does not address a specific scientific question but rather registers the patient's clinical and treatment information into a database for potential analysis in the future. Nevertheless, it is not specified if a clinical trial review was sought. To date, there are no compelling data to suggest that proton therapy is superior to or more beneficial than intensity-modulated radiation therapy or image-guided radiation therapy (IMRT/IGRT). The generally accepted standard of care for prostate cancer is to only offer proton beam therapy on clinical trials, and to not routinely offer it to patients.  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 have not been met. Therefore, we decided that the Plan does not have to pre-approve proton treatment delivery, intermediate for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve endosteal implants (D6010) and custom fabricated abutments (D6057).  You asked the Plan to pre-approve endosteal implants and custom fabricated abutments. The Plan denied your request. The Plan says these services are not covered.  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 endosteal implants (D6010) and custom fabricated abutments (D6057).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve foot orthotics.  You asked the Plan to pre-approve foot orthotics. You say that you have severe pain in your feet. Orthotics will release the pressure so you may walk better. 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 orthotics.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Transcutaneous Electrical Nerve Stimulation (TENS)
Unit (CPT E0730).
You asked the Plan to pre-approve a TENS Unit. You say that the requested TENS Unit is medically necessary.
The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested TENS Unit.
The Plan must follow Medicare rules. The rules say that TENS for chronic low back pain is covered when
specific criteria are met and when the beneficiary is enrolled in an approved clinical study meeting specific
requirements.
We looked at the file and Medicare rules. The file shows that the services are not being requested as part of an
approved clinical study. Based on this information, we decided that Medicare rules for coverage of a TENS
Unit have not been met. Therefore, we decided that the Plan does not have to pre-approve a Transcutaneous
Electrical Nerve Stimulation (TENS) Unit (CPT E0730).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve epidural steroid injections (62323).  You asked the Plan to pre-approve the epidural steroid injections. You say that the injections are medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.  The Plan follows Medicare rules. Medicare rules say that Epidural Steroid Injections are covered when records show failure of 4 weeks of non-surgical treatment which includes appropriate oral medication(s) and physical therapy to the extent tolerated.  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 epidural steroid injections. Our reviewer says that the services are not medically necessary. Our physician reviewer found the record does not show a failed 4-week trial of conservative treatment.  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 epidural steroid injections have not been met. Therefore, we decided that the Plan does not have to pre-approve epidural steroid injections (62323).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xiidra 5% solution.
You asked the Plan to pre-approve Xiidra 5% solution. You say that you would like the Plan to reconsider their
denial. The Plan denied your request. The Plan says Xiidra 5% solution is not covered under the enrollee's
Medicare Part B 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 Xiidra 5% solution.
Benefits for Xiidra 5% solution 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: 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 this is medically necessary. The Plan denied your request. The Plan says the services can be safely received in a different setting, for example: a skilled nursing facility, home with home health services, or home with outpatient therapy.
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 complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for respiratory failure, pneumonia, and congestive heart failure after recent open heart surgery. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 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 Freestyle Libre continuous glucose monitor.  You asked the Plan to pre-approve a Freestyle Libre device. You say that all your fingers are numb from testing with a needle and that you are getting to the point where you do not want to self-test because of how difficult it is becoming. The Plan denied your request. The Plan says rules for coverage for continuous glucose monitors and related supplies 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 the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a Freestyle Libre device have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for a continuous glucose monitor.
You asked the Plan to pay for 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 pay for a continuous glucose monitor
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the sacroiliac (SI)
joint.
You asked the Plan to pre-approve SI joint RFA. You say that you are appealing with supporting records. The
Plan denied your request. The Plan says the denial of authorization for this service is correct, because the
records do not show that the enrollee has had 2 diagnostic medial branch blocks that provided at least 80% pain
relief each.
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 SI joint RFA. Our reviewer says that
the requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found radiofrequency of the lateral sacral branches is considered experimental/investigational because
of the wide variation in efficacy reported in the literature.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of SI joint RFA have not been met. Therefore, we decided that the Plan does not
have to pre-approve radiofrequency ablation (RFA) of the sacroiliac (SI) joint.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve bioimpedance spectroscopy (BIS), extracellular fluid analysis for lymphedema assessments (93702).  You asked the Plan to pre-approve bioimpedance spectroscopy. You say that the enrollee is at high risk of developing lymphedema, and you believe the use of this device is medically necessary. The Plan denied your request. The Plan says this service is experimental, investigational or unproven. There is not enough scientific proof that shows the safety and/or success of bioimpedance spectroscopy for the initial diagnosis of lymphedema.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The rules also say that experimental and investigational devices are not covered.  We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of bioimpedance spectroscopy have not been met. Therefore, we decided that the Plan does not have to pre-approve bioimpedance spectroscopy (BIS), extracellular fluid analysis for lymphedema assessments (93702).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve crown, porcelain fused to predominantly base metal (CPT code D2751) and prefabricated post and core in addition to crown for tooth #14 (CPT code D2954).  You asked the Plan to pre-approve the dental services. You say that you are biting the inside of your mouth/lip and it is very sore and swollen. The Plan denied your request. The Plan says the requested crown due to the tooth not having more than half of it decayed or damaged from injury. The Plan states the post and core was denied due to no evidence of a root canal being done on this tooth in the past. The Plan states the findings were based on the notes and x-rays provided. The Plan states there is no indication that the tooth has more than half of it damaged or decayed or that a prior root canal was performed; therefore, the request for a crown and post and core are not medically necessary. The Plan states the records suggest that less invasive measures are appropriate, such as just a root canal.  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. The Plan covers the dental services when the services are medically necessary and reasonable.   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 dental services. Our physician reviewer found the documentation is insufficient to demonstrate that the requested crown, porcelain fused to predominantly base metal, and a prefabricated post and core, for tooth #14 are medically reasonable and necessary for you in this case. The documentation does not support that tooth #14 is more than half damaged or decayed, or that a prior root canal was performed. Based on this, the plan's coverage criteria have not been met in this case.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental services have not been met. Therefore, we decided that the Plan does not have to pre-approve crown, porcelain fused to predominantly base metal (CPT code D2751) and prefabricated post and core in addition to crown for tooth #14 (CPT code D2954).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.
You asked the Plan to pre-approve a shower chair. You say that the enrollee is ventilator-dependent
quadriplegic. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are
not primarily medical in nature.
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
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 require frequent daily care and skilled nursing facilities in your area do not want a patient who needs your level of care. The Plan denied your request. The Plan says the denial of authorization for IRF service is correct.
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 complexity of your nursing, medical, and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While you may need physical and/or occupational therapy, there is no documented need for an intensive rehabilitation therapy program. There is not a reasonable expectation that you will be able to fully participate in - and benefit from - the intensive rehabilitation therapy program provided in an IRF. 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) services.
You asked the Plan to pre-approve RFA services. You say that this procedure is medically reasonable and
necessary. The Plan denied your request. The Plan says this procedure is considered not medically necessary
when radiofrequency is used.
The Plan must follow Medicare rules. Medicare rules say that RFA services used for sacroiliac joint pain is
considered not medically necessary/investigational.
We looked at the file and Medicare rules. In this case, the requested RFA services will be performed for
sacroiliac joint pain which is considered investigational according to Medicare rules. Based on this
information, we decided that Medicare rules for coverage of RFA services have not been met. Therefore, we
decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) services.