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

We decided that the Plan does not have to pre-approve compression stockings identified with code A6549.
You asked the Plan to pre-approve the compression stockings. You say that the item is medically necessary.
The Plan denied your request. The Plan says this is not a covered item.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are
noncovered because they do not meet the statutory definition of a surgical dressing.
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression
stockings identified with code A6549.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility services.  You asked the Plan to pre-approve the skilled nursing facility services. You say that the SNF services are medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.  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 skilled nursing facility services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee's functional level does not require skilled therapy services with  the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment.  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 skilled nursing facility services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility services.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).  You asked the Plan to pre-approve admission to a SNF. You say that the requested admission to a SNF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF admission.  The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve admission to a SNF. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment in a SNF. The documentation does not reveal evidence of complex wound care, new enteral feedings, or other skilled nursing SNF need. The enrollee's functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment in a SNF. The enrollee does not require skilled nursing or skilled therapy services (or a combination of these services) on a daily basis in a SNF. As a practical matter this enrollee does not require the necessary services on an inpatient basis, in a skilled nursing facility setting.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of admission to a SNF have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a mastectomy sleeve.  You asked the Plan to pre-approve a mastectomy sleeve. You say that the requested item is medically necessary due to a blood clot in your arm from a stage 4 breast cancer diagnosis. You say that you had 28 lymph nodes removed from your arm and have received sleeves in the past. The Plan denied your request. The Plan says the requested device is not covered because it does not meet the definition of a prosthesis.  The Plan must follow Medicare rules. Medicare rules say that mastectomy sleeves are noncovered. Therefore, we decided that the Plan does not have to pre-approve a mastectomy sleeve.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve full braces (D8080), brace exam records (D8660) and monthly brace adjustment visit (D8670).

You asked the Plan to pre-approve orthodontic services. You say that these services are necessary. The Plan denied your request. The Plan says these services are not covered by your dental 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 full braces (D8080), brace exam records (D8660) and monthly brace adjustment visit (D8670).
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a continuation of skilled nursing facility (SNF) services.  You asked the Plan to pre-approve a continuation of SNF care. You say that there would safety concerns if you were discharged. You say that you are unable to care for yourself independently, manage your medications, or monitor your blood pressure. You say that an interruption in services could cause readmission to the hospital. The Plan denied your request. The Plan says the guidelines for coverage have not been met. The Plan says that the enrollee's needs can be met at a lower level of care.  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 a continuation of SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found [state the medical finding(s) upon which the physician based his/her conclusion]  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 continuation of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuation of skilled nursing facility (SNF) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a custom fabricated mandibular advancement oral
appliance (E0486).

You asked the Plan to pre-approve a custom fabricated mandibular advancement oral appliance. You say that
the item is medically necessary. The Plan denied your request. The Plan says as the device is not being
provided and billed for by a license dentist, the requirements per the LCD have not been met.

The Plan must follow Medicare rules. Medicare rules say that the device must be provided and billed for by a
licensed dentist (DDS or DMD).

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of a custom fabricated mandibular advancement oral appliance have not been met. Therefore, we
decided that the Plan does not have to pre-approve a custom fabricated mandibular advancement oral appliance
(E0486).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
You asked the Plan to pre-approve skilled nursing facility services for the enrollee. You say that this admission
is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria were not met.
We overturned the Plans denial. The Plan requested a reopen and stated that we did not apply the
correct criteria.
Our Medical Director looked at the reopen request and the case file. At issue is coverage for SNF services.
Our Physician Reviewer determined that criteria for coverage were met in this case. The Plan argues
that the enrollee did not require acute services and there is no clinical evidence showing she required daily
skilled therapy services. The Plan states that a pelvic fracture except under limited circumstances requires
weight bearing as tolerated. The Plan states the enrollee's care would be custodial care to support her as her
pain subsided.
The medical records show the enrollee to be an 88-year-old woman with a history of heart disease, who was
admitted on observation status to the hospital on September 26, 2021with a fracture of the right pubic ramus.
Orthopedics recommended conservative treatment. Our Medical Director has determined the Plan is correct in
this case. The documentation does not support that the enrollee in this case required skilled services daily in a
skilled nursing facility setting.
We looked at this physician's review, the file, and the Medicare rules. Based on this information, we decided
that Medicare rules for coverage of skilled nursing facility services were not met. Therefore, we decided that
the Plan does not have to provide coverage for skilled nursing facility (SNF) services for the enrollee.
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 IRF services are medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.  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 there is not a reasonable expectation that this patient 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: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).  

You asked the Plan to pre-approve admission to a SNF. You say that the requested admission to a SNF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF admission.  

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.  

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve admission to a SNF. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment in a SNF. The documentation does not reveal evidence of complex wound care, new enteral feedings, or other skilled nursing SNF need. The enrollee's functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment at a SNF level. The enrollee does not require skilled nursing or skilled therapy services (or a combination of these services) on a daily basis in a SNF. As a practical matter this enrollee does not require the necessary services on an inpatient basis, in a skilled nursing facility setting.  

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of admission to a SNF have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group four power wheelchair (K0884) and
accessories.
You asked the Plan to pre-approve a group four power wheelchair and accessories. You say that these items are
medically necessary. The Plan denied your request. The Plan says this is not a covered item.
The Plan must follow Medicare rules. Medicare rules say that Group 4 power wheelchairs (PWCs) (K0868,
K0869, K0870, K0871, K0877, K0878, K0879, K0880, K0884, K0885, K0886) have added capabilities that
are not needed for use in the home. Therefore, if these wheelchairs are provided, they will be denied as not
reasonable and necessary. If the PWC base is not covered, then related accessories will be denied.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of a group four power wheelchair and accessories have not been met. Therefore, we decided that the
Plan does not have to pre-approve a group four power wheelchair (K0884) and accessories.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation system (E2300).
You asked the Plan to pre-approve a power seat elevation system. You say that the item is medically necessary.
The Plan denied your request. The Plan says this is not a covered item.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose.
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we
decided that the Plan does not have to pre-approve a power seat elevation system (E2300).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the supply allowance for therapeutic continuous glucose
monitor (CGM) includes all supplies and accessories (K0553).
You asked the Plan to pre-approve the CGM supplies. You say that you need this item. The Plan denied your
request. The Plan says you do not meet the criteria for this item.
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 and 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 CGM
supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve the supply
allowance for therapeutic continuous glucose monitor (CGM) includes all supplies and accessories (K0553).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the enrollee does not meet criteria for IRF admission. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.
The enrollee was admitted for respiratory failure and pneumonia. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, in an intensive rehabilitation therapy program. While the enrollee has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia (J0897).
You asked the Plan to pre-approve Prolia. The Plan denied your request. The Plan says this drug is not covered for the enrollee's condition by Medicare Part B.
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be brought to the office for administration. Since the medication does not represent an expense to the physician and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that the Plan does not have to pre-approve Prolia (J0897).
Benefits for Prolia may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for evaluation and management services (99358) provided to the
enrollee on December 7, 2020.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your
request. The Plan says Medicare billing criteria are not met. We overturned the Plans denial for a lack of
sufficient claim explanation in the case file. The Plan requested a reopen and provided additional information.
The Plan says that per the National Correct Coding Initiatives (NCCI) Procedure to Procedure (PTP) an edit
exists between codes 99358 and 99310. This PTP edit has a modifier indicator of 0, which indicates there are
no modifiers that are allowed with this PTP code pair. Procedure code 99310 was billed on the same date of
service and paid. The Plan provided claim screens to confirm this information.
Based on this information, we find the Plan is correct in this case. The Plan must follow Medicare rules.
Medicare rules say that providers must report services correctly. Providers must report services with the
appropriate codes. In this case, the claim submitted cannot be paid as billed due to code 99310 being previously
paid and the procedure edit that exists between code 99310 and 99358. Medicare billing criteria have not been
met. Therefore, we decided that the Plan does not have to pay for evaluation and management services (99358)
provided to the on December 7, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve scaling and root planing (D4341) for the lower left quadrant.

You asked the Plan to pre-approve the dental services. You say that the services is necessary. The Plan denied your request. The Plan says 1 deep cleaning every 2 years, per quadrant, is covered. 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 services have not been met. Specifically, the frequency limit has been reached. The record shows that the Plan paid for scaling and root planing for the lower left quadrants that you received on October 26, 2021.

Therefore, we decided that the Plan does not have to pre-approve scaling and root planing (D4341) for the lower left quadrant.
Appeal type: Surgery
Decision: Favorable

 We decided that the Plan has to pre-approve a liver transplant.  You asked the Plan to pre-approve a liver transplant. You say that the services are necessary. The Plan denied your request. The Plan says that medical necessity has not been established. Therefore, coverage criteria have not been met.  The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 liver transplant. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found the record provided establishes the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. The elements of the coverage criteria are satisfied. The requested service is recommended.  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 liver transplant have been met. Therefore, we decided that the Plan has to pre-approve a liver transplant.   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.