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

We decided that the Plan does not have to pre-approve an electronic connection (E2310) and a phone holder
(K0108) for a power wheelchair for the enrollee.
You asked the Plan to pre-approve the connection. You say that this is medically necessary. The Plan denied
your request. The Plan says this is not medically necessary.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose.
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 connection. Our reviewer says that
the requested services are not considered medically reasonable and necessary in this case. Our physician
reviewer found the electronic connection (E2310) does not meet criteria for coverage as provided records
document that the enrollee has 4+/5 left upper extremity/hand strength and range of motion within functional
limits thus indicating she has adequate upper extremity/hand strength and function to operate the wheelchair's
power options with their own switches. The phone holder (K0108) is not covered as it does not serve a medical
need.
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 connection have not been met. Therefore, we decided that the Plan does not
have to pre-approve an electronic connection (E2310) and a phone holder (K0108) for a power wheelchair for
the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a low air loss mattress.
You asked the Plan to pre-approve a low air loss mattress. You say that you are unable to lie flat in a regular bed. The Plan denied your request. The Plan says that the documentation fails to indicate that the member has any pressure ulcers to his trunk or pelvis.
The Plan must follow Medicare rules. Medicare rules say that a group 2 support surface can be covered if the enrollee has ulcers on the trunk or pelvis. We looked at the file and Medicare rules. The file does not indicate you have or have had any ulcers on the trunk or pelvis. Based on this information, we decided that Medicare rules for coverage of a low air loss mattress have not been met. Therefore, we decided that the Plan does not have to pre-approve a low air loss mattress.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the complete upper and lower denture reline (D5750
and D5751).
You asked the Plan to pre-approve the complete upper and lower denture reline (D5750 and D5751). You say
that without the realignment your gums are exposed. You say that you cannot wait until next April for the
procedure. The Plan denied your request. The Plan says you already received the services on April 29, 2021.
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 upper and lower denture reline per plan year. The Plan paid for the upper and lower denture reline provided
on April 29, 2021, which exhausted your benefit. Therefore, we decided that the Plan does not have to preapprove
the complete upper and lower denture reline (D5750 and D5751).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of SNF services.

You asked the Plan to pre-approve continuation of SNF services. You say that continuation of SNF services is 
medically necessary. The Plan denied your request. The Plan says continuation of SNF services is not 
medically necessary.

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 continuation of SNF services. Our 
reviewer says that daily skilled services are not medically necessary. Our physician reviewer found that at the
time of admission, the enrollee required skilled rehabilitation services to improve function due to weakness and 
deconditioning. There were no skilled nursing needs. As of November 18, 2021, the enrollee did not require 
any skilled nursing or rehabilitation services on a daily basis. He was not expected to make measurable gains 
within a reasonable and predictable period of time or require skilled therapy to prevent deterioration with 
mobility or activities of daily living. The enrollee did not require skilled therapy to establish a safe and 
effective maintenance program. As a practical matter, the enrollee did not require any skilled services on an 
inpatient basis, at a SNF level of care as of November 18, 2021. The enrollee did not have any parental 
medications, complex wound care or nutrition given via a feeding tube. The enrollee received skilled care and 
improved; however, his functional improvement had plateaued by November 18, 2021, and he did not require 
any further inpatient skilled rehabilitation services. The enrollee's function was at or near his new baseline 
level of function and he could be discharged to a lower level of care for further services. As of 
November 18, 2021, the enrollee required custodial services. The denial for further inpatient skilled care is 
upheld.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continuation of SNF services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve continuation of SNF services.
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 the requested foot orthotics are a medical necessity for you. 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 waive the copayment for the office visit (99204) provided on September 13, 2021.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 copayment for medical care or surgery services in a specialty physician's office. You have been asked to pay a $35 copayment for the medical care provided in a specialty physician's office. This means that you have been asked to pay the correct amount based on your contract with the Plan.
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the office visit (99204) provided on
September 13, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services provided on June 7, 2021, by an out-of-network provider.

You asked the Plan to pay for psychotherapy services. You say that the services at issue should not be denied because you need to see your doctor. The Plan denied your request. The Plan says rules for out-of-network care have not been met.

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. 

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal.

The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for psychotherapy services provided on June 7, 2021, by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (D2740) for tooth # 5.

You asked the Plan to pre-approve the dental service. You say that the service is necessary. The Plan denied your request. The Plan says crowns are covered once per tooth every 60 months. The Plan also says that the frequency limit has been reached.

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. 

We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental service have not been met. Specifically, the file shows that the frequency limit has been reached. The record shows that the Plan paid for a crown for tooth # 5 that you received on August 18, 2020. Therefore, we decided that the Plan does not have to pre-approve a crown (D2740) for tooth # 5.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve office visits to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve these OON services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services can be provided by a network provider.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve office visits to be provided by an out-of-network (OON) provider
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable oxygen concentrator (E1392).
You asked the Plan to pre-approve a portable oxygen concentrator. You say that the system provided is very large, heavy, and difficult to transport. 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. 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 you have a stationary oxygen concentrator. A stationary oxygen concentrator serves the same purpose as the requested item. Therefore, we decided that the Plan does not have to pre-approve a portable oxygen concentrator (E1392).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve percutaneous sacroiliac joint fusion (27279).

You asked the Plan to pre-approve percutaneous sacroiliac joint fusion. You say that the requested procedure is 
a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not 
been met because the requested procedure is experimental/investigational.

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 percutaneous sacroiliac joint fusion. 
Our reviewer says that the requested services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that percutaneous sacroiliac joint fusion is experimental. More research is 
needed to demonstrate the safety and efficacy of the technique. There is no sacroiliac joint instability, fracture, 
or lesion.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of percutaneous sacroiliac joint fusion have not been met. Therefore, we decided 
that the Plan does not have to pre-approve percutaneous sacroiliac joint fusion (27279).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the heart for the enrollee.

You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your request. The Plan says the needed medical notes have not been received.

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 MRI. Our reviewer says that the requested MRI is not medically reasonable or necessary. Our physician reviewer found the enrollee has coronary disease that was defined at cardiac catheterization on 10/20/21. The documentation does not support the rationale for this imaging study. The guidelines do not support a need for this cardiac MRI in this setting. As a result, at this time the requested MRI would not be considered medically appropriate and necessary in the enrollee's clinical management. 

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 MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the heart for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion or replacement of the Optimizer Smart 
permanent cardiac contractility modulation system.

You asked the Plan to pre-approve insertion or replacement of the Optimizer Smart permanent cardiac 
contractility modulation system. You say that the services are necessary. The Plan denied your request. The 
Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.

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 insertion or replacement of the 
Optimizer Smart permanent cardiac contractility modulation system. Our reviewer says that the requested 
items/services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found while the clinical studies led to FDA approval in 2019, cardiac contractility modulation remains the 
subject of multiple studies examining long-term efficacy, as well as randomized, controlled, double-blinded 
trials to quantify clinical efficacy. Until such statistically rigorous studies are completed, it is premature to 
presume clinical outcomes and benefit. At the current time, cardiac contractility modulation system is not 
considered to be medically necessary for you.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of insertion or replacement of the Optimizer Smart permanent cardiac contractility 
modulation system have not been met. Therefore, we decided that the Plan does not have to pre-approve
insertion or replacement of the Optimizer Smart permanent cardiac contractility modulation system.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral for an out of network office visit with a
physical medicine specialist.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your
request. The Plan says there are many physical medicine specialists in the network.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the items/services at issue in this appeal. We found no exception that would require
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve
a referral for an out of network office visit with a physical medicine specialist
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve massage therapy 3 times per month.
You asked the Plan to pre-approve massage therapy. You say that you have mid to lower back pain. You say that it is relieved by massage therapy. You say that your doctor has written a prescription for you to receive massage therapy 3 times per month. The Plan denied your request. The Plan says massage therapy is not covered by Medicare or the Plan.
The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist. Therefore, we decided that the Plan does not have to pre-approve massage therapy 3 times per month.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve repeat radiofrequency ablation (RFA).

You asked the Plan to pre-approve repeat RFA. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

The Plan follows Medicare rules. Medicare rules say that the thermal radiofrequency destruction of cervical, thoracic, or lumbar paravertebral facet joint (medial branch) nerves are considered medically reasonable and necessary when specific criteria 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 repeat RFA. Our reviewer says that the services are not medically necessary. Our physician reviewer found the review has determined that the enrollee does not meet the criteria for the requested repeat RFA procedure.

The requested procedure is not medically reasonable or necessary according to the coverage criteria established in the above LCD. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of repeat RFA have not been met. Therefore, we decided that the Plan does not have to pre-approve repeat radiofrequency ablation (RFA).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from March 3, 2020, to March 6, 2020.
You asked the Plan to pay for the services. You say that the DRG adjustment should be reconsidered. The Plan denied your request. The Plan says payment of DRG 291 is not supported, as the review supports DRG 293.
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. 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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our physician reviewer found the review indicates that the documentation supported an admission for acute on chronic diastolic congestive heart failure. The documentation was inconsistent regarding a diagnosis of acute respiratory failure with hypoxia. Even though acute respiratory failure with hypoxia is documented in the history and physical, progress notes and discharge summary, supporting medical record documentation was not found within the record. Any documentation of treatment consistent with acute respiratory failure including administration of oxygen 5L or more or provision of bilateral positive airway pressure (BiPAP) and/or mechanical ventilation was not within the record. The review has determined that the records did not support the DRG and diagnosis codes used in this case. 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 inpatient hospital services provided to the enrollee from March 3, 2020, to March 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on August 11, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the office visit. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.
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.
The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the office visit provided on August 11, 2021 by an out-of-network (OON) provider