Persius/hicric huggingface dataset:
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 the portable oxygen concentrator. You say that the portable concentrator is medically necessary. The Plan denied your request. The Plan says the plan has already provided oxygen equipment to this enrollee.  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 been provided standard portable oxygen equipment. The standard portable oxygen equipment serves the same purpose as the portable oxygen concentrator. Therefore, we decided that the Plan does not have to pre-approve a portable oxygen concentrator (E1392).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a portable oxygen concentrator.  You asked the Plan to pre-approve a portable oxygen concentrator. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the portable oxygen tanks provided to you serve the same purpose as the requested portable oxygen concentrator.  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 portable oxygen tanks. The portable oxygen tanks serve the same purpose as a portable oxygen concentrator. Therefore, we decided that the Plan does not have to pre-approve a portable oxygen concentrator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve custom shoes and inserts to be rendered by the out-of-network (OON) provider.  You asked the Plan to pre-approve these items. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says there are in-network providers available to render the requested items.  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 at issue in this appeal. We found no exception that would require the Plan to pre-approve these items. Therefore, we decided that the Plan does not have to pre-approve custom shoes and inserts to be rendered by the out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an X-ray of the knee provided on September 17, 2021.  You asked the Plan to waive the copayment for the X-ray. You say that you feel the copayment should be waived since it was part of a post-operative appointment. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.  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 $5 copayment per visit for X-rays.   The file shows that while you did have surgery, the diagnostic X-rays are not included in the post-operative care. Therefore, you have been asked to pay a $5 copayment for the X-ray. X-rays fall within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. 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 an X-ray of the knee provided on September 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve crowns (D2750) for tooth #'s 28 and 29 and crowns (D2751) for tooth #'s 30 and 31.  You asked the Plan to pre-approve the crowns. The Plan denied your request. The Plan says these services are not covered under your benefit plan.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve crowns (D2750) for tooth #'s 28 and 29 and crowns (D2751) for tooth #'s 30 and 31.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve supartz or visco-3 (J7321).

You asked the Plan to pre-approve supartz or visco-3. You say that the drug is medically necessary. The Plan denied your request. The Plan says the member has not met step therapy requirements.

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 supartz or visco-3. Our reviewer says that you do not need this drug. Our physician reviewer found the file does not contain documentation of trial and failure of Orthovisc, Synvisc, or Synvisc One nor does it support that these would be less effective 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 supartz or visco-3 have not been met. Therefore, we decided that the Plan does not have to pre-approve supartz or visco-3 (J7321).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve 90 absorbent pads for the enrollee.  You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that it is not clear that you have any need for absorbent pads at this time.  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 these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. There is no documentation that the enrollee has a moderately or highly exudative full thickness wound at the site of the gastrostomy tube. Records indicate there is leakage around the gastrostomy tube possibly due to the fact that the tube's internal balloon is not sealed up against the anterior abdominal wall properly. Records from the health plan report that the enrollee has been approved for a supply of pads on another appeal and this would be a duplicate of supplies already approved. In addition, records indicate the enrollee is now in the hospital on total parenteral nutrition with unclear plans for the future use of the gastrostomy tube. Some records indicate a question as to whether the tube is actually needed for the enrollee's condition. Our physician reviewer found that the enrollee's condition does not meet criteria for these services.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve 90 absorbent pads for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve compression stockings identified with code A6545.  You asked the Plan to pre-approve the compression stockings. You say that the records should support the necessity of the service in dispute. The Plan denied your request. The Plan says the records do not show that the enrollee has an open ulcer from venous stasis.  The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6545 are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that compression bandages and gradient compression wraps are covered only when they are used as dressings over a qualifying wound.  The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you do not have a medical condition for which compression stockings can be covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6545.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a continuous glucose monitor.  You asked the Plan to pre-approve a 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 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 a continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable oxygen concentrator for the enrollee.

You asked the Plan to pre-approve a portable oxygen concentrator. You say that the enrollee needs this to go out. The Plan denied your request. The Plan says that they do not cover duplicate or redundant durable medical equipment.

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 enrollee has a home oxygen concentrator. A home oxygen concentrator serves the same purpose as a portable oxygen concentrator. Therefore, we decided that the Plan does not have to pre-approve a portable oxygen concentrator for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a neurology visit to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve the neurology visit. You say that you would like to use an out-of-network provider. The Plan denied your request. The Plan says there are network providers available.  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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve a neurology visit to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).  You asked the Plan to pre-approve IRF care. You say that this is not 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 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. You were admitted for shortness of breath and was treated for a loculated empyema. Medical problems are stable. There are no complex nursing or rehabilitation needs. You do 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 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 admission to an inpatient rehabilitation facility (IRF).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion of amniotic membrane to ocular surface; without sutures (65778).

You asked the Plan to pre-approve insertion of amniotic membrane to ocular surface. You say that the medical records provided support the necessity of the services in dispute. The Plan denied your request. The Plan says this is investigational and experimental as there is insufficient evidence that the service, procedure or supply has beneficial effect on health outcomes or is as beneficial as other alternative interventions or therapies.

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 insertion of amniotic membrane to ocular surface have not been met. Therefore, we decided that the Plan does not have to pre-approve insertion of amniotic membrane to ocular surface; without sutures (65778).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for home visits for hemodialysis provided from March 18, 2021, to July 14, 2021.  You asked the Plan to pay for home dialysis visits. You say that this service is not covered by Medicare, so you are not required to be enrolled in the Medicare program. The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider did not bill as required by Medicare coding regulations and is not enrolled in the Medicare program.  The Plan must follow Medicare rules. Medicare rules say that code 99512 is not valid for Medicare purposes and is not payable.     We looked at the file and Medicare rules. This code is not valid for Medicare purposes and is not payable. Medicare may use another code (or codes) for the reporting of these services. Based on this information, we decided that Medicare rules for coverage of home dialysis visits have not been met. Therefore, we decided that the Plan does not have to pay for home visits for hemodialysis provided from March 18, 2021, to July 14, 2021.
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 lower extremity pain, have fallen several times and cannot stand for long periods of time. 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve placement of a Superion interspinous spacer.
You asked the Plan to pre-approve the Superion procedure. You say that it is felt that this is the best treatment
option for the enrollee. The Plan denied your request. The Plan says this procedure has not been proven to be
reasonable and necessary at this time.
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 Superion procedure. Our reviewer
says that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found the enrollee is an 87-year-old female with a chief complaint of low back pain with
radicular pain to the left hip and bilateral lower extremities. The pain was 50% in the left hip and 50% in the
left lower extremity at 10/10 on the VAS. Standing worsens the pain. The enrollee was diagnosed with lumbar
spinal stenosis with neurogenic claudication.
Current evidence based medical guideline and peer reviewed literature do not fully support the spinal
decompression device procedure over the accepted standard of lumbar laminectomy. There is a lack of large
volume, long-term peer-reviewed outcome studies to support the use of this device for this enrollee's medical
condition. FDA indications include implantation of the Superion device at one or two adjacent lumbar levels in
patients with moderate spinal stenosis in whom operative treatment is indicated at no more than two levels,
from L1 to L5. This enrollee has at least moderate spinal stenosis at all lumbar levels and would not meet FDA
indications. There is severe stenosis at the planned L4-5 level, also not compatible with guidelines. FDA
contraindications include spinal instability, scoliosis, obesity, and osteoporosis, and have not been adequately
addressed in the medical records. There is imaging evidence of spondylolisthesis with no discussion of spinal
instability on flexion/extension films. There is no discussion indicating that a DEXA scan has demonstrated no
osteoporosis in this patient. Superion indirect lumbar decompression would not be considered the standard of
care for the enrollee's medical condition. Therefore, this request for Superion Vertiflex spacer at L4-5 does not
meet Medicare criteria as medically reasonable and necessary for treatment of this enrollee's medical
condition.
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 Superion procedure have not been met. Therefore, we decided that the Plan
does not have to pre-approve placement of a Superion interspinous spacer.
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 requested admission to an IRF does not meet criteria.  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 you are not appropriate for IRF level of care services. There is not a reasonable expectation presently 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says the enrollee can safely receive services in another setting.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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 physician reviewer found that the enrollee presented to the acute hospital with lower extremity cellulitis. She was treated in the hospital with intravenous antibiotics. She is weak and deconditioned. She is not presently walking, and is at a moderate to maximum assist level for transfers and some activities of daily living. Her therapy is reported to be limited by refusal to participate and the severity of her functional limitations. The complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. There is concern that she will not be able to fully participate in and benefit from the intensive rehabilitation therapy program. She does require physical and occupational therapy services, but does not require an intensive inpatient rehabilitation therapy 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.