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

We decided that the Plan does not have to pre-approve Keytruda.You asked the Plan to pre-approve these services. You say that you need the medication.The Plan denied your request. The Plan says the services are not medically necessary.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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the records show that you have newly-diagnosed esophageal cancer. You have had surgery, radiation, and chemotherapy. The tumor PDL1 score was one percent. You have not had any treatment of metastatic cancer. The use of Keytruda is not supported in this setting. Keytruda is not considered safe and effective or reasonable and 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 Keytruda.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea consultation and dental extraction with an oral surgeon.You asked the Plan to pre-approvethe services. You say thatthis is medically necessary.The Plan denied your request. The Plan says services with an oral surgeon are not covered.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers dental services when they are provided by a participating general dentist.The services are to be provided by a non-covered dental provider. Services with an oral surgeon are not covered by the dental plan. Based on this information, we decided that the Plan's rules for coverage of the services have not been met.Therefore, we decided that the Plan does not have to pre-approvea consultation and dental extraction with an oral surgeon.
Appeal type: Imaging
Decision: Unfavorable

e decided that the Plan does not have to pre-approveoncology consultation services with "the doctor".You asked the Plan to pre-approveoncology consultation services with "the doctor". You say that the enrollee would like to stay with "the provider" because she trusts the doctors.The Plan denied your request. The Plan says the necessary care is able to be safely provided in-network.Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan providers available to meet enrollees' needs. Your contract with the Plan says that, with few exceptions, you must use contract providers for care.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 oncology consultation services with "the doctor". Our reviewer says that the criteria for coverage of out-of-network care have not been met. Our physician reviewer found there is no evidence showing that the enrollee is currently receiving any active treatment and/or medical management of her condition that makes it medically necessary to receive care out-of-network. Our physician reviewer found that there is nothing unique about this enrollee's condition that would make it medically necessary for her to receive care out-of-network. Our physician reviewer found that the plan has show they have in-network specialists who have the qualifications and expertise necessary to meet the current 
medical Standards of Care required for treatment of the enrollee's condition.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of oncology consultation services with "the doctor" have not been met.Therefore, we decided that the Plan does not have to pre-approveoncology consultation services with "the doctor".
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approve the Spiration Valve System (EMPROVE) for the enrollee.
You asked the Plan to pre-approve the system. You say that daily activities are limited due to severe emphysema. The Plan denied your request. The Plan says that this is experimental.
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 the system. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has severe COPD with air trapping, and is severely symptomatic despite maximum medical therapy. The target lobe meets criteria of heterogeneous emphysema with greater severity than adjacent lobe and complete fissures. Randomized, sham-controlled clinical studies have demonstrated the risks and benefits of this procedure, including a relatively large study just published in late 2019. The procedure results in clinically important improvements in lung function and symptoms that persist to at least 12 months. There is a risk of pneumothorax in the first few days after the procedure. There are now enough clinical data that this procedure is no longer considered experimental. This enrollee meets the clinical criteria for endobronchial valve placement, which is considered 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 the system have been met. Therefore, we decided that the Plan has to pre-approve the Spiration Valve System (EMPROVE) for the enrollee.
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 the Novo TTF-100L system for the enrollee.
You asked the Plan to pre-approve these services. You say that this is the most appropriate option for the member at this time. The Plan denied your request. The Plan says that this is not a covered service.
The Plan must follow Medicare rules. Medicare rules say that tumor treatment field therapy is only covered if the beneficiary has histologically confirmed, newly diagnosed, supratentorial GBM. We looked at the file and Medicare rules. The enrollee does not have histologically confirmed, newly diagnosed, supratentorial GBM. 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 the Novo TTF-100L system for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide twenty (20) additional routine transportation trips.You asked the Plan to provide additional routine transportation trips. You say that you have missed several appointments and need to get back to therapy.The Plan denied your request. The Plan says that you have exceeded your benefit limit.Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of twenty-four (24) trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of additional routine transportation trips.Therefore, we decided that the Plan does not have to provide twenty (20) additional routine transportation trips.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gabapentin for the enrollee.
You asked the Plan to pre-approve Gabapentin. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says that this is not covered under Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Gabapentin for the enrollee.
Benefits for Gabapentin 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approvemagnetic resonance angiography (MRA) of the head and neck.You asked the Plan to pre-approvethe MRA. You say that an MRA was requested by the treating physician and should be covered since the enrollee pays her premiums.The Plan denied your request. The Plan says there are no findings for which an MRA is needed.The Plan follows Medicare rules. Medicare rules say that MRAs are covered when reasonable and necessary as described above. 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 MRA. Our reviewer says that the documentation does not support that the requested MRA is needed. Our physician reviewer found the enrollee was admitted to the hospital with hip pain and baseline dementia. There is no evidence of an acute neurologic event. Basic neurologic imaging showed evidence of old/chronic disease. There is no documentation of a plan to obtain an MRA. There is no documentation indicating how an MRA would alter the enrollee's diagnosis or treatment. Therefore, the documentation does not support that the requested MRA is medically necessary or reasonable.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the MRA have not been met.Therefore, we decided that the Plan does not have to pre-approvemagnetic resonance angiography (MRA) of the head and neck.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia for the enrollee.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 step therapy requirement is not met.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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has age-related 
osteoporosis without current pathological fracture. She is on alendronate. The records show that the enrollee has tried and failed an oral bisphosphonate, but not zoledronic acid. The zoledronic acid would not be less effective or contraindicated; therefore, Prolia is not reasonable or medically necessary at this time.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 Prolia for the enrollee
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that you are in constant pain and standing and walking is unbearable. You need the shoes because you are flat footed and obese. The Plan denied your request. The Plan says the enrollee is not diabetic and the shoe/orthotic is not an integral part of a brace or prosthetic. Therefore, this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean upper partial denture.You asked the Plan to pre-approvean upper partial denture. You say that not being able to eat is affecting your health.The Plan denied your request. The Plan says that this is not covered by your plan.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-approvean upper partial denture.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ambulance transport to the enrollee's physician's office.You asked the Plan to pre-approve ambulance transport. You say that the enrollee needs this until his hip heals.The Plan denied your request. The Plan says that a physician's office is not a covered destination.The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when they meet certain origin and destination requirements. A doctor's office is not a covered destination. The services you have asked the Plan to pre-approve are ambulance transport services to a doctor's office.Therefore, we decided that the Plan does not have to pre-approve ambulance transport to the enrollee's physician's office.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a 120-hour video electroencephalographic EEG (Home) monitoring and routine EEG to be provided by the out of network provider.You asked the Plan to pre-approve the physician services. You say that the requested service is necessary to differentiate between non-epileptic and epileptic seizures. You say it is necessary to further determine the enrollee's therapeutic regimen.The Plan denied your request. The Plan says the requested services can be provided by the in network neurologist.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 pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has confirmed there is a network provider available who can provide the items/services at issue in this appeal. The record shows that you have an appointment scheduled with him on December 23, 2019 to pick up the monitoring equipment. We found no exception that would require the Plan to pre-approve these items/services.Therefore, we decided that the Plan does not have to pre-approve a 120-hour video electroencephalographic EEG (Home) monitoring and routine EEG to be provided by the out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hearingaids to beprovided by you.You asked the Plan to pre-approve the hearing aids. The Plan denied your request. The Plan says the enrolleemust receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.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 provide coverage forcare from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve the requested hearing aids.Therefore, we decided that the Plan does not haveto pre-approve the requested hearing aids.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean exception to the 50 mile limit for routine transportation.You asked the Plan to pre-approveexceptions to supplemental benefits. You say that you need this to get to an office visit.The Plan denied your request. The Plan says that your request exceeds the 50 mile limit.Medicare does not cover routine transportation. While plans may offer supplemental transportation benefits they are not required to do so. Medicare does not provide exceptions to supplemental benefits.Therefore, we decided that the Plan does not have to pre-approvean exception to the 50 mile limit for routine transportation.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF admission and services. You asked the Plan to pre-approve SNF services. You say that the enrollee has not recovered to her baseline level of function.The Plan denied your request. The Plan says the enrollee does not require daily skilled therapy or nursing services.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 SNF services. Our physician reviewer found that the enrollee's current level of function is standby assist with bed mobility, contact guard assist/standby assist with transfers, contact guard assist with toilet transfers, ambulating 60 feet and to and from the bathroom with a rolling walker with contact guard assist/standby assist, minimal assist with toileting. There are no noted daily skilled complex nursing needs. She is ambulating household distances and requires little assistance with mobility and transfers. While she may benefit from continuing physical and occupational therapy, the records do not support the need for daily therapy.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean office visit to beprovided by an out of network provider.You asked the Plan to pre-approvean office visit. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested services can be provided by a network provider.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 pre-approved care.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-approvean office visit to be provided.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvefoot orthotics.You asked the Plan to pre-approvefoot orthotics. You say that coverage for the foot orthotics should be reconsidered because the enrollee has plantar fasciitis.The Plan denied your request. The Plan says this item is not a covered benefit.Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.  Records show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. Although orthotics may be appropriate fortheenrollee, neither Medicare nor the Plan provides coverage of orthotics for their condition.Therefore, we decided that the Plan does not have to pre-approvefoot orthotics.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an upper complete denture (D5110) and a lower complete denture (D5120).
You asked the Plan to pre-approve the dentures. You say that dentures are medically necessary as you have periodontal disease and had to have teeth removed for health reasons. The Plan denied your request. The Plan says dentures are not a covered benefit under your policy.
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 dentures requested are not among those items covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an upper complete denture (D5110) and a lower complete denture (D5120).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an attendant control for the enrollee.You asked the Plan to pre-approve an attendant control. The Plan denied your request. The Plan says that the requested attendant control cannot be covered in addition to a beneficiary-operated joystick per Medicare rules.The Plan must follow Medicare rules. Medicare rules say that if an attendant control is provided in addition to a beneficiary-operated drive control system, it will be denied as non-covered.We looked at the file and Medicare rules. An attendant control cannot be covered in addition to the enrollee-operated device control system already approved by the plan. Based on this information, we decided that Medicare rules for coverage of an attendant control have not been met.Therefore, we decided that the Plan does not have to pre-approve an attendant control for the enrollee.