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

We decided that the Plan does not have to pre-approve an oximeter.
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. Medicare rules say that oximeters are denied as non-covered.
We looked at the file and Medicare rules. The item at issue is an oximeter. This item is not covered by
Medicare. Therefore, we decided that the Plan does not have to pre-approve an oximeter.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an FDG Positron Emission Tomography (PET) scan.
You asked the Plan to pre-approve an FDG PET scan. You say that a FDG PET scan is medically necessary. The Plan denied your request. The Plan says Medicare guidance says outside of a clinical trial, Medicare only covers FDG PET scans when a patient meets the rules for diagnosing both of two separate conditions. The PET scan is used to tell which of the two conditions is the correct one. These conditions are fronto-temporal dementia (FTD) and Alzheimer's disease (AD). The PET scan is only covered if the doctor cannot tell the two apart after there has been after extensive testing.
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are medically necessary. 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 FDG PET scan. Our reviewer says that a FDG PET scan is not medically necessary. Our physician reviewer found that the enrollee is noted to have dementia. The medical records indicate she is primarily suspected of having Alzheimer's Dementia. According to the applicable NCD, a FDG PET scan is only covered to differentiate between patients who meet diagnostic criteria for both AD and FTD and for whom additional criterion are met. There was no indication in the records that the enrollee was suspected of having both AD and FTD. Rather the notes only strongly suggest AD. In this setting, the requested study cannot be said to have been ordered for an indication for which the NCD covers this service. 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 FDG PET scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a FDG PET scan
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA).
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 a third procedure is not covered.
The Plan must follow Medicare rules. The 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 request is for a third RFA session within 12 months. No more than two sessions per region are covered per rolling 12 months. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation (RFA).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an interspinous spacer placement (22870, 22869).
You asked the Plan to pre-approve the interspinous spacer placement. You say that the procedure is medically necessary. The Plan denied your request. The Plan says this procedure is investigational and non-covered.
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 interspinous spacer placement. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found interspinous process distraction devices remain experimental. More research is needed to show safety and efficacy. 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 interspinous spacer placement have not been met. Therefore, we decided that the Plan does not have to pre-approve an interspinous spacer placement (22870, 22869).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional power wheelchair accessories (K0108, E2300, E2311, E2313, E2377) 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 upper limb strength and function are adequate for the enrollee to be able to control the power options using their own switches which are included in the allowance of these power options.
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 based on the medical records provided, there is no documentation that the enrollee meets Medicare criteria for the requested additional accessories. The records document that the enrollee has 3+/5 to 4/5 bilateral upper extremity strength and is independent with eating, grooming, toileting and hygiene thus indicating he has adequate upper extremity strength and function to control the wheelchair's power options with their own switches. 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 additional power wheelchair accessories (K0108, E2300, E2311, E2313, E2377) for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services provided on May 12, 2021, billed with
two units of 21556.
You asked the Plan to pay for the surgical services as billed. You say that this should be paid in full. The Plan
denied your request. The Plan says the code 21556 is not supported or payable.
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 21556 is excision of subfascial or intramuscular tumors
whose resected area is less than 5 cm.
We asked our coder 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 surgical services as billed. Our reviewer says that the
code billed is not supported. Our reviewer found the Operative Report did not include documentation of an
excision of a subfascial (intramuscular) tumor, from the soft tissue of the neck or anterior thorax, less than 5
cm, for the two units requested.
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the surgical services as billed have not been met. Therefore, we decided that the
Plan does not have to pay for the surgical services provided on May 12, 2021, billed with two units of 21556
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a fluid circulating cold pad with a pump (E0218).
You asked the Plan to pre-approve a fluid circulating cold pad with a pump. You say that this was
recommended to improve your circulation. The Plan denied your request. The Plan says this is not covered.
The Plan must follow Medicare rules. Medicare rules say that a fluid circulating cold pad with pump (E0218)
will be denied as not reasonable and necessary.
We looked at the file and Medicare rules. The item at issue is not considered reasonable and necessary. Based
on this information, we decided that Medicare rules for coverage of a fluid circulating cold pad with a pump
have not been met. Therefore, we decided that the Plan does not have to pre-approve a fluid circulating cold
pad with a pump (E0218).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a profile power wheelchair lift, swing away outside lift, license plate riser, and hitch and wiring install.
You asked the Plan to pre-approve the items. You say that this is medically necessary. The Plan denied your request. The Plan says this is not for use inside the home.
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 item at issue in this appeal is for use outside of the home. Although this item 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 a profile power wheelchair lift, swing away outside lift, license plate riser, and hitch and wiring install.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for additional non-emergency, routine
transportation trips.
You asked the Plan to provide coverage for additional non-emergency, routine transportation trips. You say
that you still have medical appointments in December and need additional transportation trips. The Plan denied
your request. The Plan says you have used twenty-four (24) one-way trips of the twenty-four (24) one-way
trips covered by your health Plan for the year 2021.
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 a maximum of 24 one-way trips per year.
We looked at your request, the records in the case file, and the rules. Based on this information, we decided
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we
decided that the Plan does not have to provide coverage for additional non-emergency, routine transportation
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve custom foot orthotics.  You asked the Plan to pre-approve foot orthotics. You say that this was a recommendation from the doctor. 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 custom foot orthotics.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the MyoPro myoelectric orthosis (L8702).  You asked the Plan to pre-approve the orthosis. You say that the MyoPro is at least as beneficial as existing and available medically appropriate alternatives. The Plan denied your request. The Plan says this item is considered experimental and investigational. More studies are needed to show MyoPro is safe and effective.  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 the orthosis have not been met. Therefore, we decided that the Plan does not have to pre-approve the MyoPro myoelectric orthosis (L8702).
Appeal type: Surgery
Decision: Partially Favorable

We decided that the Plan has to pay for 23412. We decided that the Plan does not have to pay for 29826.
You asked the Plan to pay for the denied codes. You say that this should be paid for. The Plan says that the records do not support the services billed.
We decided that the Plan has to pay for CPT 23412.
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 CPT 23412 is "Repair of ruptured musculotendinous cuff (eg, rotator cuff) open; chronic." We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request for CPT 23412. Our reviewer says that the services represented by CPT 23412 were supported by the medical records. Our physician reviewer found that the operative note dated 3/22/21 appropriately documented the repair of ruptured musculotendinous cuff (eg, rotator cuff) open; chronic. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 23412 have been met. Therefore, we decided that the Plan has to pay for 23412.
We also decided that the Plan does not have to pay for CPT 29826.
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 CPT 29826 is "Arthroscopy, shoulder, surgical; decompression of subacromial space with partial acromioplasty, with coracoacromial ligament (ie, arch) release, when performed (List separately in addition to code for primary procedure)." We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request for CPT 29826. Our reviewer says that the services represented by CPT 29826 are not supported in the medical records. Our physician reviewer found that the operative note dated 3/22/21 does not include documentation of decompression of subacromial space with partial acromioplasty, with coracoacromial ligament release. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 29826 have not been met. Therefore, we decided that the Plan does not have to pay for 29826.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
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 the monitor. You say that it is important to her to maintain your glucose levels with this monitor. The Plan denied your request. The Plan says the criteria is not 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 or 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 the monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the shoulder, elbow, wrist, or hand.
You asked the Plan to pre-approve the imaging. You say that this is medically necessary. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically necessary. 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 imaging. Our reviewer says that the requested imaging is not medically reasonable or necessary. Our physician reviewer found the physical exam of the left shoulder had no detail whatsoever, thus it is impossible to determine if there is a red flag mandating immediate MRI without first trying a conservative course of therapy including six week trial of monitored physical therapy. Absent such data the medical necessity of MRI of the left shoulder can't be established. It is also noted that the x-rays showed degenerative changes of the acromioclavicular (AC) joint, and the shoulder injection was of the glenohumeral joint. Typically an injection with AC joint degenerative changes would occur in the subacromial space not the glenohumeral joint. 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 imaging have not been met. Therefore, we decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the shoulder, elbow, wrist, or hand.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Caster Forks (E2396 x4).  You asked the Plan to pre-approve Caster Forks (E2396 x4).. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says there are Caster Forks already included within the approved wheelchair model's assemblies. The Plan says that the request for an extra 4 Caster Forks coded as E2396 x4 is not covered.  The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary.  The file shows that the approved repairs already include 4 Caster Forks.  These serve the same purpose as the additional Caster Forks (E2396 x4) being requested. Therefore, we decided that the Plan does not have to pre-approve Caster Forks (E2396 x4).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) segmental pneumatic appliance (E0667).
You asked the Plan to pre-approve a pneumatic compression device and appliance. You say that you disagree with the denial rationale and ask for review of the enclosed documentation supporting medical necessity of the prescribed Flexitouch PCD. 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) segmental pneumatic appliance (E0667).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a guided tissue regeneration (D4266) to be provided by a participating provider.
You asked the Plan to pre-approve a guided tissue regeneration. You say that you would like the Plan to approve and pay for this dental work. The Plan denied your request. The Plan says the requested dental service 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, 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 guided tissue regeneration (D4266) to be provided by a participating provider.
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 SNF admission. You say that SNF care is needed. The Plan denied your request. The Plan says you do not require daily skilled services.
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 SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee is a female with meningioma and seizure disorder who was admitted to the hospital due to increased confusion. She has been diagnosed with epilepsy and had to have multiple medication changes that leg to encephalopathy/delirium. She has stabilized medically and ready for discharge. The most recent therapy documentation indicates the member requires assistance with eating due to confusion and mild to moderate assistance with self-care tasks and mobility. Her cognitive impairment has limited her ability to cooperate meaningfully with therapy services. The member has stabilized medically and is ready for discharge from the hospital. The member does not require skilled nursing and/or skilled therapy services on a daily basis. She is medically stable and can receive further rehab services at a lower level of care. Although further rehab services would be appropriate to improve function, as a practical matter, the intermittent skilled services can be provided at a lower level of care than a skilled nursing facility. 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 SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).