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

We decided that the Plan does not have to pre-approve an electronic connection between wheelchair controller and two or more power seating system motors.

You asked the Plan to pre-approve an electronic connection between wheelchair controller and two or more power seating system motors. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says you do not meet criteria for the requested item.

The Plan must follow Medicare rules. Medicare rules say that an electronic connection between wheelchair controller and two or more power seating system motors are only covered for certain indications. 

We looked at the file and Medicare rules. Review of the file shows that your left upper extremity strength and function are adequate to control the power option using its own switch which are included in the allowance of the power option approved by the Plan. Based on this information, we decided that Medicare rules for coverage of an electronic connection between wheelchair controller and two or more power seating system motors have not been met. Therefore, we decided that the Plan does not have to pre-approve an electronic connection between wheelchair controller and two or more power seating system motors.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 2 additional physical therapy visits in your home (G0151).

You asked the Plan to pre-approve the home health services. You say that the additional visits are medically necessary. The Plan denied your request. The Plan says the requested services are not medically necessary.

The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 

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 home health services. Our reviewer says that the requested home health services are not medically necessary. Our physician reviewer found the enrollee does not have documented, ongoing, home health physical therapy needs. The reviewer found that the enrollee is functioning at a level commiserate with a lower level of care (i.e. HEP, outpatient therapy). Therefore, the reviewer found that the requested home health physical therapy services are not medically necessary or reasonable. 

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 home health services have not been met. Specifically, the file does not indicate that the enrollee has documented, ongoing, home health physical therapy needs. Therefore, we decided that the Plan does not have to pre-approve 2 additional physical therapy visits in your home (G0151).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 10 additional physical therapy visits.

You asked the Plan to pre-approve 10 additional physical therapy visits. You say that the physical therapist does things you cannot do on your own. You say that you are requesting one visit per week for 10 weeks. The Plan denied your request. The Plan says additional visits are not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.

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 10 additional physical therapy visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found that you have previously been treated with outpatient therapy and should be independent with a home exercise program. Our reviewer says that the additional therapy services are not an appropriate duration and frequency for treatment of your medical condition and are not medically necessary. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 10 additional physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 10 additional physical therapy visits.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet joint blocks.
You asked the Plan to pre-approve facet joint blocks. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.
The Plan follows Medicare rules. Medicare rules say that facet joint blocks are only covered for certain indications.
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 facet joint blocks. Our reviewer says that the documentation does not support that the requested services are medically reasonable or necessary. Our physician reviewer found the enrollee has low back pain due to lumbosacral spondylosis with facet joint arthropathy. The documentation does not support any indication that diagnostic blocks were performed to confirm facet joint as primary source of pain. It is also unclear if non-operative/conservative management was tried or failed (other than Aleve). In this case, there was no evidence of a failure of conservative measures and also there was no evidence of performing a diagnostic block. Therefore, the enrollee does not meet criteria for the requested 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 facet joint blocks have not been met. Therefore, we decided that the Plan does not have to pre-approve facet joint blocks.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve evaluation and management services with a
chiropractor.
You asked the Plan to pre-approve the evaluation and management services with a chiropractor. You say that
you need the therapy services to help relieve the pain that you get from sitting up straight. The Plan denied your
request. The Plan says the non-manipulative services from a chiropractor are not a covered benefit under
Medicare or your contract.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is
manual manipulation of the spine to correct a subluxation.
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that
the Plan does not have to pre-approve evaluation and management services with a chiropractor
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve custom shoe inserts coded as L3000.
You asked the Plan to pre-approve the requested shoe inserts. You say that you believe that these inserts are
necessary to help you to walk properly given your condition. The Plan denied your request. The Plan says the
codes requested are not for diabetic shoe inserts. These are being requested for treatment for plantar fasciitis.
There is no evidence that they are being requested to treat the covered diabetes-related conditions of the feet.
The Plan must follow Medicare rules. Medicare rules say that shoe inserts may be covered when used in a shoe
that is an integral part of a leg brace. In addition, they may be covered when used as treatment for diabetic foot
disease, when the criteria listed in the Medicare rules section are met.
We looked at the file and Medicare rules. There is no indication that you have any of the conditions listed as
covered for use with diabetic shoes. In addition, the code requested is not for diabetic shoes. Though these may
be appropriate treatment for plantar fasciitis, neither Medicare nor the Plan covers these inserts for this
condition. Based on this information, we decided that Medicare rules for coverage of the requested shoe inserts
have not been met. Therefore, we decided that the Plan does not have to pre-approve custom shoe inserts coded
as L3000
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 the enrollee continues to have a need for skilled therapy with ongoing safety
concerns and a potential for functional improvement however, the documentation doesn't support that he would
meet criteria for admission to an acute inpatient rehabilitation facility. There is no indication that the enrollee
would require skilled rehabilitation in an IRF, participating in rehab services 15 hours a week, under the
supervision of a physician with at least 3 visits weekly to regain or maintain his functional status. The enrollee
can receive services at a lower level of care.
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the semi-precision attachments (D6192).

You asked the Plan to pre-approve the semi-precision attachments (D6192). You say that you would like to place two locators in the new lower denture, so the patient is able to effectively use the denture. You say that without the locators the denture isn't usable, and reimbursement should be considered. The Plan denied your request. The Plan says the 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 the semi-precision attachments (D6192).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a radiofrequency ablation procedure (64636, 64635).

You asked the Plan to pre-approve the ablation procedure. You say that the services are 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 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 record shows the enrollee has already had 2 radiofrequency ablation sessions in the past 12 months. Based on this information, we decided that Medicare rules for coverage of the ablation procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve a radiofrequency ablation procedure (64636, 64635).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Hyaluronan Acid injection (J7326).

You asked the Plan to pre-approve the Hyaluronan Acid injection. The Plan denied your request. The Plan says the criteria has not been met.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use. 

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 Hyaluronan Acid injection. Our reviewer says that the Hyaluronan Acid injection is not medically reasonable and necessary. Our physician reviewer found there is no documentation of adequate conservative measures for knee pain to include physical therapy. 

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 Hyaluronan Acid injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a Hyaluronan Acid injection (J7326).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and segmental pneumatic appliance (E0667).

You asked the Plan to pre-approve a pneumatic compression device and appliance. You say that a pneumatic compression pump has been deemed medically necessary to allow the enrollee to properly manage her chronic lymphedema. 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 records do not show the enrollee has lymphedema extending into the chest trunk or abdomen.

The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required. 

We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and segmental pneumatic appliance (E0667).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an interspinous spacer placement (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 the procedure is experimental 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 spinal decompression and interspinous process decompression systems for the treatment of lumbar spinal stenosis are unproven and not medically necessary due to insufficient evidence of 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 (22869)
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bone growth stimulator (E0760).
You asked the Plan to pre-approve a bone growth stimulator. 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. The rules say that an electrical bone growth stimulator is covered for
nonunion of long bone fractures. Nonunion of long bone fractures is considered to exist only when serial
radiographs have confirmed that fracture healing has ceased for 3 or more months prior to starting treatment
with the electrical bone growth stimulator. Serial radiographs must include a minimum of 2 sets of radiographs
separated by a minimum of 90 days.
In this case, nonunion of a long bone fracture is not considered to exist under Medicare rules. The file does not
show that there were 2 or more serial radiographs separated by 90 or more days confirming that healing had
ceased. Therefore, we decided that the Plan does not have to pre-approve a bone growth stimulator (E0760).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an interspinous spacer placement (22869).
You asked the Plan to pre-approve the interspinous spacer placement. You say that this 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 the record indicates that the enrollee has multi-level degenerative disease with
mild to moderate central and foraminal stenosis. The record does not state that the enrollee is not indicated for
operative intervention at no more than two levels. The record does no indicate that pain is relieved in flexion.
The procedure is not medically appropriate.
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 (22869).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a wheelchair to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve the wheelchair from an OON provider. You say that the records provided support the need for the wheelchair in dispute. The Plan denied your request. The Plan says there are network providers who can supply the item(s) needed.

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 wheelchair to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve implant placement (D6010), bone replacement graft (D4263), custom fabricated abutment (D6057), and abutment supported crown (D6059).
You asked the Plan to pre-approve the dental services. You say that you cannot feel anything on the side of your mouth. You say that you are on a liquid diet because you cannot chew food. You say that you lost jawbone from an infection and extraction. You also say that you need a crown on tooth # 12. The Plan denied your request. The Plan says the requested dental services are not listed as covered.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested dental services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve
implant placement (D6010), bone replacement graft (D4263), custom fabricated abutment (D6057), and abutment supported crown (D6059).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the cone beam CT capture provided (D0367).
You asked the Plan to pre-approve the cone beam CT capture provided (D0367). The Plan denied your request. The Plan says the 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 the cone beam CT capture provided (D0367).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve supplies for a continuous glucose monitor (CGM).
You asked the Plan to pre-approve the CGM supplies. You say that the enrollee benefits greatly from use the
CGM due to his frequent use of steroids which can affect blood sugar levels. He also has episode of
hypoglycemia unawareness which can be life-threatening without the alerts from the CGM device. It is felt that
the CGM is medically necessary given his condition. The Plan denied your request. The Plan says Medicare
criteria for the coverage of the CGM have not been met.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations,
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment
plan.
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin
with at least three daily administrations and does not require frequent self-adjustment of insulin dosage based
on the blood glucose testing results.. Although the use of a CGM may be helpful/appropriate, the Medicare
coverage criteria for this device have not been met. Therefore, we decided that the Plan does not have to pre-
approve supplies for a continuous glucose monitor (CGM)