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

We decided that the Plan does not have to pre-approve a Group 3 power wheelchair with single power option
(K0856) and accessories.
You asked the Plan to pre-approve Group 3 power wheelchair with single power option and accessories. You
say that the enrollee needs a Group 3 power wheelchair and needs the tilt system for pressure relief and
positioning. The Plan denied your request. The Plan says the denial of authorization for this device is correct,
because the enrollee does not qualify for a Group 3 power wheelchair with single power option and may
instead qualify for a Group 3 power wheelchair with no power options.
The Plan follows Medicare rules. Medicare rules state that a Group 3 power wheelchair with single power
option may be covered if the criteria described in the previous 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 Group 3 power wheelchair with single
power option and accessories. Our reviewer says that the enrollee does not meet the Medicare criteria for the
requested wheelchair and components. Our physician reviewer found the documentation does not indicate that
there is a medical need for a special drive control or for a power tilt or recline. There is no evidence that the
enrollee is at high risk for a pressure ulcer, has increased tone or spasticity that needs a special seating system,
or uses intermittent catheterization. The requested wheelchair exceeds the enrollee's medical needs.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Group 3 power wheelchair with single power option and accessories have not
been met. Therefore, we decided that the Plan does not have to pre-approve a Group 3 power wheelchair with
single power option (K0856) and accessories.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the transcutaneous electrical modulation pain reprocessing
(0278T) you received on July 22, 2021
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is an experimental
service.
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 pay for the services. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found that the record indicates that the requested service is for detoxification and stress management. There is
insufficient literature to support the use of the requested service for the enrollee's condition. The record
provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, of the
requested service.
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 services have not been met.
Therefore, we decided that the Plan does not have to pay for the transcutaneous electrical modulation pain reprocessing (0278T) you received on July 22, 2021
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skin barrier wipes (A5120).
You asked the Plan to pre-approve skin barrier wipes. You say that it is medically necessary for the enrollee to
use the barrier wipes as long as she is on insulin pump therapy. The Plan denied your request. The Plan says
skin barrier wipes are only covered for members with an ostomy. Based on the records provided, the enrollee
does not have an ostomy and the barrier wipes are for use with your insulin pump.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of skin barrier wipes have not been met. Therefore, we decided that the Plan does not have to pre-
approve skin barrier wipes (A5120).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the transcutaneous electrical modulation pain reprocessing (0278T) provided to you on July 19, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is an experimental service.
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 pay for the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the record indicates that the requested service is requested for detoxification and stress management. There is insufficient literature to support the use of the requested service for the enrollee's condition. The record provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, of
the requested service. 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 services have not been met. Therefore, we decided that the Plan does not have to pay for the transcutaneous electrical modulation pain reprocessing (0278T) provided to you on July 19, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (87486, 87496, 87498, 87532, 87541, 87581, 87640, 87798 and 87502) provided on August 27, 2020.
You asked the Plan to pay for the laboratory services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the submitted claim form indicates the laboratory specimen was obtained in a office, POS 11; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in a nursing facility POS 32.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We find that CPT codes 87486, 87496, 87498, 87532, 87541, 87581, 87640, 87798 and 87502 are not supported in the medical record. Specifically, the claim was billed with an office place of service code while the records indicate that the member's face-to-face service was rendered in a nursing facility setting. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services (87486, 87496, 87498, 87532, 87541, 87581, 87640, 87798 and 87502) provided on August 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bitewing images (D0274), intraoral periapical images (D0220), periodic oral evaluation (D0120), and prophylaxis (D1110), provided on June 15, 2021.
You asked the Plan to pay for the dental services.. You say that you did not know the provider was out-of-network. The Plan denied your request. The Plan says services are not covered for out of network providers.
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 bitewing images (D0274), intraoral periapical images (D0220), periodic oral evaluation (D0120), and prophylaxis (D1110), provided on June 15, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve septoplasty and submucous resection of turbinate for the enrollee.
You asked the Plan to pre-approve the procedures. You say that this is medically necessary. The Plan denied your request. The Plan says there is an absence of evidence of sinusitis.
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 procedures. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found it is documented that the enrollee was complaining of drainage coming from the sinus. The impression was that she has very severe and aggressive rhinitis. A scan on 5/7/21 was negative, showing no evidence of sinusitis. On 8/18/21 it is documented that the enrollee was told very clearly that there is no sinus condition, and that the surgeon would be happy to do turbinoplasty, but that the enrollee should stay on Flonase. The clinical documentation in the case file does not support that septoplasty and submucous resection of turbinate are medically reasonable and necessary for the enrollee in this case.
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 procedures have not been met. Therefore, we decided that the Plan does not have to pre-approve septoplasty and submucous resection of turbinate for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient behavioral health admission and services.
You asked the Plan to pre-approve inpatient behavioral health admission and services. You say that you do not feel safe discharging the enrollee currently and feel the enrollee needs an inpatient setting. The Plan denied your request. The Plan says the requested admission to an inpatient behavioral health center does not meet criteria.
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 inpatient behavioral health admission and services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee was not placed on the CIWA protocol (a scale to measure alcohol withdrawal) measurements, as the enrollee did not present with alcohol withdrawal symptoms. The enrollee had no problems at work or with her hygiene or grooming or with loss of energy or interest in activities. The enrollee had no problems with sleep or appetite or thoughts to harm herself or others. The enrollee was not currently showing any alcohol withdrawal symptoms. There was no medical indication for an inpatient admission to a behavioral health center.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient behavioral health admission and services have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient behavioral health admission and services.
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 inpatient rehabilitation is medically necessary for
this enrollee. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. The
enrollee's ongoing skilled therapy and nursing needs can be provided in 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 that 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. 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. There is not a reasonable expectation that this enrollee
will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an
IRF.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan
denied your request. The Plan says the enrollee's records show that the enrollee had a successful amputation,
and the enrollee is convalescing but the enrollee will need routine skilled nursing evaluation of the surgical site
for infection and continued intravenous antibiotics. The Plan states the enrollee is recovering from an acute
illness. The Plan states the enrollee will need continued care, including skilled nursing and physical therapy.
The Plan states the enrollee can safely receive this care in another setting, such as an inpatient rehabilitation
facility (IRF), a skilled nursing facility (SNF) or at home with home health services or outpatient setting if
appropriate.
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 enrollee was admitted with osteomyelitis of the foot and sepsis. The record
indicates that the enrollee has a prolonged hospital course, is improving and continues to require acute care
services. The enrollee continues to receive acute care services, and these have not been denied. The medical
record does not indicate that the enrollee requires services that they are not currently receiving but that would
be available at the LTACH facility. The elements of the coverage rules 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 the LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve 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)
and supplies.
You asked the Plan to pre-approve a CGM and supplies. You say that this is medically necessary. The Plan
denied your request. The Plan says that a standard home blood glucose monitor appears appropriate for the
member's current blood glucose testing needs.
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 you do not use insulin with at least three daily injections. 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 Freestyle Libre continuous glucose monitor (CGM) and supplies.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for transcutaneous electrical modulation pain reprocessing
(0278T) provided July 15, 2021.
You asked the Plan to pay for transcutaneous electrical modulation pain reprocessing. You say that the services
were medically necessary. The Plan denied your request. The Plan says this 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 pay for transcutaneous electrical modulation pain
reprocessing.
Our reviewer says that the requested services are not considered medically reasonable and necessary in this
case. Our physician reviewer found there is insufficient literature to support the use of the requested service for
the enrollee's condition. The records provided do not establish medical necessity.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of transcutaneous electrical modulation pain reprocessing have not been met.
Therefore, we decided that the Plan does not have to pay for transcutaneous electrical modulation pain
reprocessing (0278T) provided July 15, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an open magnetic resonance imaging (MRI).
You asked the Plan to pre-approve an open MRI. You say that you are bleeding and the need for the requested
MRI is urgent. The Plan denied your request. The Plan says they have been unable to obtain a doctor's order or
the required information despite numerous attempts.
The Plan must follow Medicare rules. Medicare rules say that information must be submitted to confirm that
Medicare coverage criteria have been met.
We looked at the file and Medicare rules. The case file we received did not include any medical records. There
is evidence that the Plan made reasonable attempts to obtain this documentation. Without medical records, we
do not have evidence that the requested open MRI is medically necessary. Based on this information, we
decided that Medicare rules for coverage of an open MRI have not been met. Therefore, we decided that the
Plan does not have to pre-approve an open magnetic resonance imaging (MRI).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the tetanus-diphtheria (Td) vaccine provided on March 15,
2021.
You asked the Plan to pay for the Td vaccine. You say that you did not realize you would need prior
authorization to get the standard scheduled tetanus shot since it had been 10 years since your last one. The Plan
denied your request. The Plan says this vaccine is only covered when provided due to direct exposure or injury.
This was a routine booster which is not covered under Medicare Part B.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the Td vaccine. The
Plan follows the same rules.
Records do not show that you have been injured or directly exposed to any illness related to the Td vaccine.
Therefore, we decided that the Plan does not have to pay for the tetanus-diphtheria (Td) vaccine provided on
March 15, 2021.
Benefits for the Td vaccine 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient services from December 12, 2021,
to December 15, 2021.
You asked the Plan to pre-approve continued inpatient care. You say that you need a lot of assistance because
you cannot walk, and you fall a lot. You need hospital care until you can be accepted into another facility. The
Plan denied your request. The Plan says the requested inpatient services are not medically necessary in this
case. You can safely receive the necessary services in an observation level of care.
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 continued inpatient care. Our reviewer
says that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found you had fallen at home and injured your hip and shoulder. You were reported to have
had difficulty walking with a history of falling often. Supervision was recommended until placement was
confirmed. You were hemodynamically stable and did not require any acute care treatments. Supervision was
needed only until placement that could be safely administered at the observation level of care. Therefore, the
requested inpatient services from December 12, 2021, to December 15, 2021, will be considered not medically
necessary without sufficient support made for such.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of continued inpatient care have not been met. Therefore, we decided that the Plan
does not have to pre-approve continued inpatient services from December 12, 2021, to December 15, 2021.