Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Clonidine injections.  You asked the Plan to pre-approve the injections. You say that this is medically necessary. The Plan denied your request. The Plan says this is not approved by the Food and Drug Administration (FDA) to treat the enrollee's condition.  The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 injections. Our reviewer says that the requested injections are not medically reasonable or necessary. Our physician reviewer found the record indicates that the enrollee has a diagnosis of  lumbar pain with radiculopathy not related to cancer. The Food and Drug Administration has not stated that the requested drug is indicated for the enrollee's condition. The Medicare approved  drug compendia do not contain a supportive citation for the use of the requested drug in the enrollee's clinical situation. The elements of the coverage criteria are not satisfied.  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 injections have not been met. Therefore, we decided that the Plan does not have to pre-approve Clonidine injections.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the office visit to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve the office visit. You say that these services with an OON provider are medically reasonable and necessary. The Plan denied your request. The Plan says they have in-network providers available to provide the care you need.  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 the office visit 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 Dexcom continuous glucose monitor (CGM).  You asked the Plan to pre-approve a Dexcom CGM. You say that you need this Dexcom because you cannot keep your sugar level under control. The Plan denied your request. The Plan says you do not meet criteria for the requested device.  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 a Dexcom CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a Dexcom continuous glucose monitor (CGM).
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Prolia.  You asked the Plan to pre-approve Prolia. You say that this is medically necessary. The Plan denied your request. The Plan says that you have not tried and failed zoledronic acid.  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 Prolia. Our reviewer says that that Prolia is not medically reasonable and necessary. There is no documentation provided indicating that the Plan's required drug would likely be less effective and/or likely have adverse effects for you. Our physician reviewer found that your condition does not meet step therapy criteria for Prolia.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve compression stockings identified with code A5630.  You asked the Plan to pre-approve the compression stockings. You say that you are being discriminated against because of your pre-existing health condition. The Plan denied your request. The Plan says the dressings are non-covered.  The Plan must follow Medicare rules. Medicare rules say that compression stockings 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.  We looked at the file and the rules. The medical records provided show that you need compression stockings for your chronic lymphedema. 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. Furthermore, the requested compression stockings described by code A6530 are noncovered because they do not meet the statutory definition of a dressing. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A5630.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the immediate lower denture (D5140) and unspecified removable prosthodontic procedure (D5899) provided on July 15, 2021.  You asked the Plan to pay for the prosthodontic services. You say that these services were necessary. The Plan denied your request. The Plan says these items 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 pay for the immediate lower denture (D5140) and unspecified removable prosthodontic procedure (D5899) provided on July 15, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.  You asked the Plan to pre-approve the LTACH services. You say that the clinical documentation provided supports the need for LTACH care. The Plan denied your request. The Plan says the guidelines for coverage of LTACH care have not been met. The Plan says that the enrollee's needs could be provided in another setting.  The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.  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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.  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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve continuous positive airway pressure (CPAP) accessories, mask liners, and strap covers.  You asked the Plan to pre-approve these services. You say that the enrollee gets a rash and imprints on her face without the accessories. The Plan denied your request. The Plan says the services are not covered.  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. Therefore, we decided that the Plan does not have to pre-approve continuous positive airway pressure (CPAP) accessories, mask liners, and strap covers.
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 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 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 does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary 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: 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 you disagree with the denial rational and ask for review of the enclosed documentation supporting medical necessity of the prescribed Flexitouch PCD. The Plan denied your request. The Plan says the enrollee does not meet the LCD criteria for an advanced lymphedema pump as there is no failed four-week trial of a basic pneumatic compression device of either E0650 or E0651.  The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required.  We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and segmental pneumatic appliance (E0667).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve 8 physical therapy (PT) visits.  You asked the Plan to pre-approve the 8 PT visits. You say that the enrollee suffers from bilateral achilles tendonitis and would benefit from skilled physical therapy services in order to increase strength, range of motion, and functional mobility. The Plan denied your request. The Plan says this request does not meet medical necessity criteria.  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 the 8 PT 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 the additional requested therapy is not generally accepted as specific and effective therapy for the patient's condition beyond what was approved by the health plan. The patient has had prior therapy and the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or by or under the supervision of a therapist. Our reviewer found that a July 28, 2021 foot and ankle provider progress note states that the patient has normal coordination to the right and left lower extremity. Sensation, reflexes are normal. The patient can heel and toe walk with ease. There is decreased pain right calcaneus to palpation. The patient has persistent difficulty with stairs per therapy notes but the documentation does not support that she requires ongoing skilled professional therapy. The patient has been instructed in and is compliant in a home exercise program. Our physician reviewer also found that the requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain the patient's current condition or to prevent or slow further deterioration.  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 8 PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 8 physical therapy (PT) visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a semi-electric hospital bed.  You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.  The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered medically necessary when the patient:  1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or  2. Requires attachments which can only be attached to a hospital bed; AND  3. Requires frequent changes in body position and/or has an immediate need for a change in body position.  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 services are not medically necessary. Our physician reviewer found the enrollee has arthritis and back pain as well as multiple chronic medical conditions, but the records do not clearly document that his condition requires position of the body in ways not feasible in an ordinary bed or frequent changes in body position or immediate changes in body position. The records do not document that he requires special attachments that cannot be fixed and used on an ordinary bed. The semi-electric hospital bed is not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a semi-electric hospital bed.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an Intracept procedure.  You asked the Plan to pre-approve the requested services. You say that the enrollee needs relief from their ongoing pain. The Plan denied your request. The Plan says unproven procedures are considered not reasonable and necessary.  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 requested services. Our physician reviewer found that the Intracept procedure is experimental., More research is needed to show safety and efficacy of the procedure.  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 requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve an Intracept procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve diabetic shoes (A5500) and inserts (A5514) to be provided by an OON provider.  You asked the Plan to pre-approve diabetic shoes and inserts. You say that there is not an on-network provider for these items. The Plan denied your request. The Plan says these items are available in-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 diabetic shoes (A5500) and inserts (A5514) to be provided by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a power scooter (E1230).  You asked the Plan to pre-approve a power scooter. You say that you are not able to walk, The Plan denied your request. The Plan says your needs could be met with a manual wheelchair.  The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home.   The records indicate that the item at issue in this appeal is for community use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pre-approve a power scooter (E1230).
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a leadless pacemaker (33274).  You asked the Plan to pre-approve a leadless pacemaker. You say that the requested device is medically reasonable and necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met.  The Plan must follow Medicare rules. Medicare rules say that leadless pacemakers are only covered through certain Medicare approved studies.   We looked at the file and Medicare rules. In this case, the enrollee is not in a Medicare-approved study. Based on this information, we decided that Medicare rules for coverage of a leadless pacemaker have not been met. Therefore, we decided that the Plan does not have to pre-approve a leadless pacemaker (33274).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and accessory (E0667).  You asked the Plan to pre-approve a pneumatic compression device and accessory. You say that the enrollee cannot use a simple pump. The Plan denied your request. The Plan says the enrollee has not had a trial with a basic pump.  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 accessory (E0667).