Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve destruction of lower or sacral spinal facet joint nerves.
You asked the Plan to pre-approve destruction of lower or sacral spinal facet joint nerves. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that the thermal radiofrequency destruction of cervical, thoracic, or lumbar paravertebral facet joint (median branch) nerves are considered medically reasonable and necessary when specific criteria are met.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve destruction of lower or sacral spinal facet joint nerves. Our reviewer says that the services are not medically necessary. Our physician reviewer found the request is not medically reasonable and necessary. Two sets of diagnostic MBBs which produce greater than 80% is required by the LCD. This was not achieved. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of destruction of lower or sacral spinal facet joint nerves have not been met. Therefore, we decided that the Plan does not have to pre-approve destruction of lower or sacral spinal facet joint nerves.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and supplies.
You asked the Plan to pre-approve a CGM and supplies. You say that you feel this item should be approved. The Plan denied your request. The Plan says the enrollee does 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 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 CGM and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and supplies
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Contour Next One kit.
You asked the Plan to pre-approve the Contour Next One kit. You say that you would like reconsideration
because the requested kit is medically necessary. The Plan denied your request. The Plan says the records do
not show that you have tried and failed the Plan's preferred brand.
The Plan must follow Medicare rules. Medicare rules say that MA plans may specify brands and manufacturers
as preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those
preferred brands and manufacturers.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the Contour Next One kit. have not been met. Specifically, the record does not indicate that you
have tried the Plan's preferred brand. The documentation submitted does not show that you are unable to use
this brand for medical reasons. Therefore, we decided that the Plan does not have to pre-approve the Contour
Next One kit.
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 enrollee currently meets all IRF criteria. The Plan denied your request. The Plan says the enrollee can be treated at a lower level of care.
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 patient does not require treatment by multiple therapies and an intensive rehabilitation therapy program. While the documentation does support a need for physical or occupational
therapy, there is no documented need for a intensive, multi-disciplinary rehabilitation program. 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 6 additional speech therapy visits. 
 
You asked the Plan to pre-approve 6 additional speech therapy visits. You say that you attached additional 
supporting clinical documentation. 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 6 additional speech 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 the patient has had prior extensive therapy for 
this condition, is on a regular diet and his speech deficits are not significant that he requires ongoing skilled 
speech therapy. Our reviewer says that the unique skills of a professional therapist are not required to safely 
and effectively provide ongoing 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 6 additional speech therapy visits have not been met. Therefore, we decided that 
the Plan does not have to pre-approve 6 additional speech therapy visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the OneTouch Ultra test strips for the enrollee.
You asked the Plan to pre-approve the test strips. You say that this is medically necessary. The Plan denied your request. The Plan says this is not the preferred brand.
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 test strips. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no data given as to why the enrollee cannot use the preferred brands for monitoring blood glucose levels. Hence, the requested brand does not meet the coverage criteria. 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 test strips have not been met. Therefore, we decided that the Plan does not have to pre-approve the OneTouch Ultra test strips for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the chair portion of a lift chair.
You asked the Plan to pre-approve the chair. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The rules say that seat lift chairs are not covered. Coverage is limited to a seat lift mechanism.
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 the chair portion of a lift chair
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a seat lift mechanism.
You asked the Plan to pre-approve the mechanism. You say that this is medically necessary. The Plan denied your request. The Plan says there are no indications for this request.
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions listed in the Medicare rules section are met. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the mechanism. Our reviewer says that the requested mechanism is not medically reasonable or necessary. Our physician reviewer found based on the medical records provided, there is no documentation that you have severe arthritis of the hip or a neuromuscular disease. Her diagnoses are left shoulder arthritis, biceps tendon instability and rotator cuff disease. There is no clear documentation that a seat lift is included in the treating practitioner's course of treatment. A seat lift is not likely to effect improvement in your condition, or arrest or retard deterioration in
your condition. The provided records do not show that you are completely incapable of standing from a chair in the home. 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 mechanism have not been met. Therefore, we decided that the Plan does not have to pre-approve a seat lift mechanism.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a transformal computer prosthesis.
You asked the Plan to pre-approve a transformal computer prosthesis. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested item is not a covered benefit.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. 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 record does not contain a valid physician order for the requested supplies in this case. In addition, the documentation supports that your current prosthesis fits you correctly. Therefore, we decided that the Plan does not have to pre-approve a transformal computer prosthesis
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve transvenous phrenic nerve stimulator (0424T).
You asked the Plan to pre-approve transvenous phrenic nerve stimulator. You say that the enrollee meets
reasonably accepted requirements for medical necessity. Enclosed are clinical records documenting the
enrollee's history of symptoms and treatments that were tried and failed. The Plan denied your request. The
Plan says this procedure is considered experimental and investigational and is not covered by Medicare.
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 transvenous phrenic nerve stimulator have not been met. Therefore, we decided that the Plan does
not have to pre-approve transvenous phrenic nerve stimulator (0424T).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the cervical
spine.
You asked the Plan to pre-approve an MRI of the cervical spine. You say that the services are necessary. The
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been
met.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically
necessary.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve an MRI of the cervical spine. Our
reviewer says that the services are not medically necessary. Our physician reviewer found the requested service
is not medically necessary and reasonable for the diagnosis and treatment for the enrollee's clinical condition at
this time. The elements of the coverage criteria are not satisfied. The requested service cannot be
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 an MRI of the cervical spine have not been met. Therefore, we decided that the
Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the cervical spine.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable ventilator (E0466).
You asked the Plan to pre-approve a portable ventilator. You say that the item is medically necessary. The Plan denied your request. The Plan says the item is not medically necessary.
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a portable ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a portable ventilator (E0466).
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve 3D imaging for a MRI of the pelvis.
You asked the Plan to pre-approve the 3D imaging. You say that this is medically necessary. The Plan denied your request. The Plan says that there are no results of a recent pelvis MRI that showed a high or very high chance of cancer.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the 3D imaging. Our reviewer says that the requested 3D imaging is medically reasonable and necessary. Our physician reviewer found the current urology literature advocates the use of MRI with 3D rendering in order to analyze the prostate in patients suspected of having prostate cancer. The technique provides optimal visualization of the entire gland and targets any suspicious area for targeted biopsy which then yields better results for therapy planning than the old transrectal ultrasonography with random biopsy. 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 3D imaging have been met. Therefore, we decided that the Plan has to pre-approve 3D imaging for a MRI of the pelvis.
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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a supply allowance for a therapeutic continuous glucose 
monitor (CGM) (K0553). 
 
You asked the Plan to pre-approve the supply allowance for a CGM. The Plan denied your request. The Plan 
says you do not meet the criteria for coverage. 
 
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 the supply 
allowance for a CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
supply allowance for a therapeutic continuous glucose monitor (CGM) (K0553).
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 a transfer to a LTACH is medically 
necessary. The Plan denied your request. The Plan says continued acute hospital stay was offered, until the 
enrollee can discharge to a lower level of care. 
 
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 the member is no longer on mechanical ventilation and antibiotics have been 
completed. 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 Plan. 
 
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 a Freestyle Libre continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the Freestyle Libre CGM. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the requested item is not a covered benefit. 
 
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. Based on this information, we decided that Medicare rules for coverage of 
the Freestyle Libre CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve 
a Freestyle Libre continuous glucose monitor (CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve extracranial-intracranial (EC-IC) arterial bypass 
surgery. 
 
You asked the Plan to pre-approve EC-IC arterial bypass surgery. You say that the services are necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan follows Medicare rules. Medicare rules say that extracranial-Intracranial (EC-IC) arterial bypass 
surgery is not a covered procedure when it is performed as a treatment for ischemic cerebrovascular disease of 
the carotid or middle cerebral arteries, which includes the treatment or prevention of strokes. 
 
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 EC-IC arterial bypass surgery. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found in this case, the 
record indicates that the enrollee has ischemic cerebrovascular disease and a bypass to the middle cerebral 
artery is planned. The elements of the coverage criteria are not satisfied. The requested service is not 
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 EC-IC arterial bypass surgery have not been met. Therefore, we decided that the 
Plan does not have to pre-approve extracranial-intracranial (EC-IC) arterial bypass surgery.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a wheelchair ramp for the enrollee. 
 
You asked the Plan to pre-approve a wheelchair ramp. You say that a wheelchair ramp is medically necessary 
for the enrollee to leave the home. The Plan denied your request. The Plan says wheelchair ramps are not 
covered by the Plan or by Medicare. 
 
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 rules state that equipment must serve a medical purpose. A wheelchair 
ramp is for 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 
wheelchair ramp for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home infusion services.  
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
service being requested is not covered under Medicare.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code.  
We looked at the file and the rules. We find that CPT codes requested are not valid for Medicare purposes. 
Medicare uses another code for the reporting of, and payment for, these services. Based on this information, we 
decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have 
to pre-approve home infusion services.