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

 We decided that the Plan does not have to pre-approve the knee scooter (CPT code E0118).  You asked the Plan to pre-approve the knee scooter. You say that you need a knee scooter because you cannot get around freely due to foot injury (bone marrow edema). You state you cannot put weight/walk on right foot for an undetermined healing time. You state it will prevent you from falling and causing any further injury. The Plan denied your request. The Plan says the determination is that there is insufficient published clinical literature demonstrating safety and effectiveness in the Medicare population to establish the medical necessity for these products.  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 knee scooter. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not support that you require the use of a knee scooter for mobility-related activities of daily living. The medical necessity is not supported.  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 knee scooter have not been met. Therefore, we decided that the Plan does not have to pre-approve the knee scooter (CPT code E0118).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve extractions.
You asked the Plan to pre-approve the dental services. You say that you were advised by a plan representative
that this would be covered, and you would only have a copay. You also say that this should be covered. The
Plan denied your request. The Plan says the requested services are not covered.
Medicare generally does not cover dental services. The Plan follows the same rule.
The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement
of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or
paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve extractions.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that you require an LTACH admission. The 
Plan denied your request. The Plan says you are receiving appropriate in-patient acute care and are currently 
unstable for transfer to an LTACH.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that you appear to be improving but still somewhat unstable and may require shortterm additional acute care services that may be continued safely at the current facility for now. You do not 
require services at the LTACH that are not already available at the current facility. There are no services at the 
LTACH that you require that are not already available and covered at the current facility. Transfer to LTACH 
is not medically necessary as it would not be clinically advantageous. Transfer to a lower level of care may be 
considered when treatment has completed and you are more stable.
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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Eliquis tablet.
You asked the Plan to pre-approve Eliquis. You say that the requested drug is medically necessary for the
enrollee. The Plan denied your request. The Plan says the requested drug is considered self-administered. The
Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also
says the requested drug is not covered under Medicare Part B.
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 Eliquis tablet.
Benefits for Eliquis may be available under Medicare Part D. Contact the Plan that administers Part D benefits
for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the pneumatic compression device billed with codes E0675 and E0673 for date of service July 14, 2021.
You asked the Plan to pay for the pneumatic compression device. You say that that this device is not experimental or investigational and should be covered. The Plan denied your request. The Plan says this device is not covered for the patient's condition.
The Plan must follow Medicare rules. Medicare rules say that pneumatic compression devices coded as E0675 are only covered for the treatment of peripheral artery disease. Use of this device for any other condition will be denied as not reasonable and necessary.
The diagnosis billed with this device was N40.1, which is benign prostatic hyperplasia, not peripheral artery disease. Items coded with E0675 are not covered for this condition. Because the compression device itself is not covered, the accessory also billed (code E0673) is also non-covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the pneumatic compression device have not been met. Therefore, we decided that the Plan does not have to pay for the pneumatic compression device billed with codes E0675 and E0673 for date of service July 14, 2021.
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 admission to a SNF. You say that the requested admission to a SNF is 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF 
admission.
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 admission to a SNF. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the enrollee is with cerebral vascular 
accident (CVA), currently in IRF. From a nursing perspective, the enrollee received oral medications. The 
enrollee had stable vital signs. She had routine foley catheter care. She was treated for pain. Regarding 
rehabilitation services, the enrollee received physical therapy, occupational therapy, and speech therapy. The 
enrollee was at a minimal to maximal assist level with functional mobility including gait to 80 feet. She had 
mild oropharyngeal dysphagia. She required varying assist with activities of daily living.
There are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs. The 
enrollee does not require skilled nursing or therapy services on a daily basis. This 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 admission to a SNF 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 a power elevating seat (E2300) for a power wheelchair.  You asked the Plan to pre-approve a power elevating seat. You say that the requested item is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage for the requested item have not been met.  The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature (E2300) and power standing feature (E2301) are non-covered because they are not primarily medical in nature. Based on this information, we decided that Medicare rules for coverage of a power elevating seat have not been met. Therefore, we decided that the Plan does not have to pre-approve a power elevating seat (E2300) for a power wheelchair.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Freestyle Libre continuous glucose monitor (CGM) with supplies.
You asked the Plan to pre-approve the CGM and supplies. The Plan denied your request. The Plan says the coverage criteria are not met.
The Plan follows Medicare rules. Medicare rules say that a CGM and supplies are covered when the coverage criteria in the applicable LCD are met. 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 CGM and supplies. Our reviewer says that the requested CGM and supplies are not medically reasonable and necessary. Our physician reviewer found that there is no documentation that the enrollee in this case meets all of the coverage criteria (1-5) in the applicable LCD for coverage of the requested continuous glucose monitor. The records do not indicate the enrollee's diabetes is insulin-treated with multiple (three or more) daily administrations of insulin or a continuous subcutaneous insulin infusion (CSII) pump. The enrollee is reported to be on Lantus insulin once daily. 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 CGM and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve the Freestyle Libre continuous glucose monitor (CGM) with supplies.
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 admission to a SNF. You say that the requested admission to a SNF is
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF
admission.
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 admission to a SNF. Our reviewer says
that daily skilled services are not necessary. Our physician reviewer found the enrollee is with falls, chronic
obstructive pulmonary disease (COPD), alcoholism, diabetes, and anemia. From a nursing perspective, the
enrollee received oral medications. The enrollee had stable vital signs. Regarding rehabilitation services, the
enrollee received physical therapy. The enrollee was at a minimal assist level with functional mobility
including gait to 50 feet x 4.
There are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs. The
enrollee does not require skilled nursing or therapy services on a daily basis. This 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 admission to a SNF 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for imaging services provided to the enrollee on July 28, 2021.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request.
The Plan says this procedure is considered inclusive to another procedure.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
In this case, we have confirmed that code 75710 is a column II code to column I code 37227. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for imaging services provided to the enrollee on July 28, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of Durolane.
You asked the Plan to pre-approve Durolane. You say that you are appealing with supporting records. The Plan
denied your request. The Plan says the denial of authorization for this drug is correct, because the Plan requires
a trial of Orthovisc, Synvisc, or Synvisc-One before it approves Durolane.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain
Part B medications.
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 Durolane. Our reviewer says that the
enrollee does not meet the Medicare criteria for a step therapy exception for Durolane. Our physician reviewer
found the enrollee has not tried and failed the Plan's preferred drugs of Orthovisc, Synvisc, or Synvisc-One.
The record does not show that these drugs would likely be less effective and/or have adverse effects for the
enrollee.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Durolane have not been met. Therefore, we decided that the Plan does not have
to pre-approve use of Durolane.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Eliquis.
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 self-administered drugs are not covered.
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 Eliquis.
Benefits for these services 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 the requested admission to an IRF is medically
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.
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
enrollee does not meet criteria for IRF admission. 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 has a past medical history of stroke and is living
at home with ongoing weakness despite home health physical therapy services. 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, in an intensive rehabilitation therapy program. While the enrollee has 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient level of care for a colonoscopy.
You asked the Plan to pre-approve acute inpatient hospital care. You say that you want to stay overnight in the hospital so your colonoscopy prep can be monitored. The Plan denied your request. The Plan says the denial of authorization for inpatient level is correct, because your needs can be met at an observation level of care.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that you do not meet the Medicare criteria for inpatient hospital admission. Our physician reviewer found a colonoscopy is not a Medicare inpatient-only procedure. There is no information showing that
you require inpatient admission, symptoms from colonoscopy preparation could be addressed in observation care. An admitting physician would not reasonably expect your necessary hospital care to span at least 2 midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient level of care for a colonoscopy.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on July 6, 2021.
You asked the Plan to pay for the services. You say that the test was deemed medically necessary for the treatment and management of the enrollee. The Plan denied your request. The Plan says laboratory procedures must be performed by the contracted laboratory.
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. We decided that the Plan does not have to pay for laboratory services provided to the enrollee on July 6, 2021.
You asked the Plan to pay for the services. You say that the test was deemed medically necessary for the treatment and management of the enrollee. The Plan denied your request. The Plan says laboratory procedures must be performed by the contracted laboratory.
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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve multi-axial rotation unit ('mcp' or equal) (CPT code L5986) and flex-walk system or equal (CPT code L5981).
You asked the Plan to pre-approve the items. You say that the items are necessary. The Plan denied your request. The Plan says the records they have do not show why the requested advanced foot is needed.
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 items. Our physician reviewer found the documentation does not support that you are a K3 ambulator or that there is a need for an advanced foot and ankle feature to the prosthesis. 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 items have not been met. Therefore, we decided that the Plan does not have to pre-approve multi-axial rotation unit ('mcp' or equal) (CPT code L5986) and flex-walk system or equal (CPT code L5981).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for electrocardiogram services (procedure code 93000) provided to the enrollee on March 25, 2021.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says this was not billed with a correct place of service.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 93000 is "Electrocardiogram, routine ECG with at least 12 leads."
We find that CPT code 93000 is not supported in the medical record. Specifically, this was not billed with the appropriate place of service. 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 pay for electrocardiogram services (procedure code 93000) provided to the enrollee on March 25, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve testosterone solution (J3490).  You asked the Plan to pre-approve the testosterone solution. You say that the requested drug is medically necessary. The Plan denied your request. The Plan says the requested drug is considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the requested drug is not covered under Medicare Part B.  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 testosterone solution (J3490).   Benefits for the testosterone 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.