Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the primary closure of sinus perforation (D7261).

You asked the Plan to pre-approve the primary closure of sinus perforation. You say that the service requested
is medically necessary for your condition. The Plan denied your request. The Plan says the services is not
covered under your benefit package.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the
primary closure of sinus perforation (D7261).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea maxillary partial denture (flexible base) for the enrollee.You asked the Planto pre-approvethe denture. You say that this should be paid for.The Plandenied your request. The Plansaysthis is not a covered service.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 Plandoes not haveto pre-approvea maxillary partial denture (flexible base) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have topre-approvea cranial prosthesis (wig).You asked the Plan to pre-approvewig. You say that you are appealing.The Plan denied your request. The Plan says the denial of authorization for this item is correct, because a wig is not covered by Medicare.Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are ordered by a physician. The Plan follows these same rules.In this case, although the wig may be appropriate, it does not meet the definitionof the above benefit categories. It is not considered DME because it does not directly treat a medical condition. It does not meet the Medicare definition of a prosthetic because it does not replace an internal body organ or attached tissue. As such, it is noncovered by Medicare. Furthermore, the Plan does not offer a supplemental benefit which would provide coverage for a wig.Therefore, we decided that the Plan does not have to pre-approvea cranial prosthesis (wig).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network provider for
miscellaneous supplies/accessories.

You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your
request. The Plan says this is an out-of-network request with no information provide justifying the medical
necessity of this DME.

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
a referral to an out-of-network provider for miscellaneous supplies/accessories.
Appeal type: Outpatient Therapies
Decision: Favorable

We decided that the Plan has to pre-approve three (3) PT visits.
You asked the Plan to pre-approve the three (3) PT visits. You say that your physician advised you to have
home PT. The Plan denied your request. The Plan says that Medicare allows home physical therapy only for
specific medical diagnoses. In the enrollee's case, physical therapy is not allowed for the diagnoses that was
requested.
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 three (3) PT visits. Our reviewer
says that the PT is medically reasonable and necessary. Our physician reviewer found that the requested 3 PT
sessions would be considered generally accepted as specific and effective therapy for your condition. You have
demonstrated mobility and balance deficits at the hospital and it is reasonable to have home health for three (3)
sessions to ensure safety in the home setting with an assistive device. You appear home bound as leaving the
home requires the assistance of another person or an assistive device and it would be a taxing effort. Three (3)
sessions with the unique skills of a professional therapist to ensure safety and provide treatment under a
therapist supervision is appropriate. The three (3) sessions would allow for review of an independent home
exercise program. The specialized skill, knowledge and judgment of a qualified therapist to establish, design
and/or deliver a program to maintain your current condition or to prevent or slow further deterioration for three
(3) additional sessions is appropriate and 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 three (3) PT visits have been met. Therefore, we decided that the Plan has to
pre-approve three (3) PT visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the surgical placement of endosteal implants (D6010)
for teeth # 3, 6, 11, and 14.

You asked the Plan to pre-approve the dental services. You say that you have been having issues with your
dentures and implants are the best option for you. You say that the dentures have been adjusted multiple times
with no success. You also say that with proper fitting teeth, you will be able to get back to a healthier diet for
your health issues. The Plan denied your request. The Plan says the surgical placement of endosteal implants is
not listed as a covered service.

Medicare generally does not cover dental services. The Plan follows the same rule.

The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement
of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or
paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve the surgical placement
of endosteal implants (D6010) for teeth # 3, 6, 11, and 14.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Remicade (J1745).

You asked the Plan to pre-approve the Remicade. You say that Remicade is medically necessary. The Plan
denied your request. The Plan says a trial of Inflectra or Renflexis is required before alternatives like Remicade
can be approved.

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 the Remicade. Our reviewer says that
Remicade is not medically necessary. Our physician reviewer found the record shows no trial of the plan
preferred drugs, or any reason why the plan preferred drugs would be unsafe or ineffective for this enrollee.

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 Remicade have not been met. Therefore, we decided that the Plan does not
have to pre-approve Remicade (J1745).
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve a pneumatic compression device identified with code E0652 and
appliances identified with code E0667.
You asked the Plan to pre-approve a pneumatic compression device and appliances. You say that you would
like the plan to reconsider their denial. The Plan denied your request. The Plan says that the requested items are
not medically necessary.
The Plan follows Medicare rules. Medicare rules say that a pneumatic compression device (PCD) coded as
E0652 and appliances are covered 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 a pneumatic compression device and appliances. Our reviewer says that the documentation supports that the requested pneumatic compression
device is medically reasonable and necessary. Our physician reviewer found the enrollee has been diagnosed
with bilateral lower extremity lymphedema. It was noted that the enrollee had tried 20-30 mmHg compression
stockings and leg elevation which had significant improvement. The enrollee has also tried a lymphedema
basic pump without improvement and is noted to have worsening groin and abdominal edema currently. The
provided records support the patient having at least a 4-week period of regular, daily, multiple-hour usage of a
basic pneumatic compression device to justify a trial of the E0652 device. Therefore, the enrollee meets criteria
for the requested E0652 device.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of a pneumatic compression device and appliances have been met. Therefore, we
decided that the Plan has to pre-approve a pneumatic compression device identified with code E0652 and
appliances identified with code E0667.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a prefabricated post and core in addition to a crown
(D2954) for tooth # 11.

You asked the Plan to pre-approve the dental service. You say that the service is medically necessary. The Plan
denied your request. The Plan says prefabricated post and core in addition to a crown is not listed as a covered
service. The Plan also says that any services not listed 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.

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. The Customer Handbook clearly states that if a dental item or service
is not listed in the benefit chart then it is not covered. Therefore, we decided that the Plan does not have to preapprove
a prefabricated post and core in addition to a crown (D2954) for tooth # 11.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a total electric hospital bed.

You asked the Plan to pre-approve a total electric hospital bed. 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 a total electric hospital bed is not covered.

While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital
bed.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a cervical spine CT scan.

You asked the Plan to pre-approve a cervical spine CT scan. You say that you would like the plan to reconsider
their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are
medically necessary.

We looked at the file and Medicare rules. Review of the file shows that no medical records were submitted to
support that the requested services would be medically necessary for you. Based on this information, we
decided that Medicare rules for coverage of a cervical spine CT scan have not been met. Therefore, we decided
that the Plan does not have to pre-approve a cervical spine CT scan.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ExosomeDx Prostate genetic testing.

You asked the Plan to pre-approve genetic testing. You say that the enrollee is at high risk for prostate cancer,
and this testing is clinically proven to predict the likelihood of high-grade prostate cancer before a biopsy is
necessary. The Plan denied your request. The Plan says the denial of authorization for this testing is correct,
because this testing is experimental/investigational.

The Plan follows Medicare rules. Medicare rules state that ExosomeDx Prostate testing is only covered under
certain, specific indications.

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 genetic testing. Our reviewer says that
the enrollee does not meet the Medicare criteria for the requested testing. Our physician reviewer found the
enrollee has a greater than 3-year history of elevated prostate-specific antigen (PSA). In 2017 he had a negative
prostate biopsy with PSA level of 6ng/ml. ConfirmDx test was methylation negative at that time. The most
recent PSA was 10.5ng/ml.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan does not
have to pre-approve ExosomeDx Prostate genetic testing.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and
accessories (E0667).

You asked the Plan to pre-approve a pneumatic compression device. You say that a E0650 or E0651 PCD is
not appropriate for this enrollee. The Plan denied your request. The Plan says a trial of E0650 or E0651 is
required by Medicare criteria.

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 accessories (E0667).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an additional 18 PT visits.

You asked the Plan to pre-approve an additional 18 PT visits. The Plan denied your request. The Plan says
based on the clinical information received, the member is stable to continue rehabilitation with the home
exercise program and follow-up with their physician.

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 an additional 18 PT visits. Our
reviewer says that skilled services are not medically reasonable and necessary to restore or maintain function or
to prevent deterioration of the enrollee's condition. Our physician reviewer found that based on the available
records, the enrollee appears to have improved with the 24 treatments with physical therapy. Further formal
therapy at this point does not appear to be likely to achieve any significant improvement in the enrollee's
symptoms or functional status versus continued work with a home exercise program. There is no
documentation 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 under the supervision
of a therapist. Further formal therapy at this point does not appear to be likely to achieve any significant
improvement in the enrollee's symptoms or functional status versus continued work with a home exercise
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 an additional 18 PT visits have not been met. Therefore, we decided that the
Plan does not have to pre-approve an additional 18 PT visits.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home visit for assistance with activities of daily living
and personal care (per visit), (99509).
You asked the Plan to pre-approve the home visit. You say that you are requesting attendant services while you
are at work because the enrollee has Alzheimer's and leaves the home and need's assistance with bathing,
cleaning and feeding. The Plan denied your request. The Plan says the requested services are considered
custodial care services and is not covered.
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically
necessary for the enrollee to receive skilled nursing or therapy. Custodial care is not covered.
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the home visit have not been met. Therefore, we decided that the Plan does not have to pre-approve
home visit for assistance with activities of daily living and personal care (per visit), (99509).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) and a complete
mandibular denture (D5120).

You asked the Plan to pre-approve the complete maxillary and mandibular dentures. You say that you are
unable to wear your current dentures, and are limited to eating softer foods. The Plan denied your request. The
Plan says these services exceed the maximum count allowed per period.

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, complete maxillary denture (D5110)
and complete mandibular denture (D5120) are each limited to one procedure every five plan years. The record
shows that you received a complete maxillary denture (D5110) and a complete mandibular denture (D5120) on
May 12, 2016 and your complete maxillary denture (D5110) and complete mandibular denture (D5120)
benefits have been exhausted. Therefore, we decided that the Plan does not have to pre-approve a complete
maxillary denture (D5110) and a complete mandibular denture (D5120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the complete maxillary denture services (D5110).

You asked the Plan to pre-approve the complete maxillary dentures. You say that these services are medically
necessary for your condition. The Plan denied your request. The Plan says this service exceed the maximum
count allowed per period.

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 the complete
maxillary dentures once every five years.

We looked at the file and Medicare rules. The file indicates that you had this procedure done in 2018 which
means you have exhausted your benefit for complete maxillary dentures. Based on this information, we decided
that the Plan's rules for coverage of the complete maxillary dentures have not been met. Therefore, we decided
that the Plan does not have to pre-approve the complete maxillary denture services (D5110).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Medical Alert.
You asked the Plan to pre-approve Medical Alert. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the requested services are 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 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 Medical Alert.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the core buildup (D2950).

You asked the Plan to pre-approve the core buildup. You say that the service is medically necessary for the
enrollee. The Plan denied your request. The Plan says this service is not covered by the 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-approve the
core buildup (D2950).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy services to be provided by an out of
network (OON) provider.

You asked the Plan to pre-approve OON services. You say that the enrollee is at high risk for falls. The Plan
denied your request. The Plan says the enrollee's needs can be met by an in-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 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 services at issue in this appeal. We found no exception that would require the
Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve
physical therapy services to be provided by an out of network (OON) provider.