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

We decided that the Plan does not have to pre-approve a continuous glucose monitor system.You asked the Plan to pre-approvea continuous glucose monitor. You say that because of memory loss the enrollee is not checking glucose levels and a continuous glucose monitor would prevent hypoglycemia and hyperglycemia.The Plan denied your request. The Plan says the enrollee has not been checking glucose levels four or more times a day and does not insulin inject three or more times a day.The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered only when they are medically reasonable and necessary and replace a blood glucose monitor.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a continuous glucose monitor have not been met.Therefore, we decided that the Plan does not have to pre-approve a  continuous glucose monitor system
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a grab bar.You asked the Plan to pre-approve a grab bar. You say that you are a handicapped individual and have difficulty in staying upright in the shower. You say that you are a fall risk and have nothing to steady yourself while in the shower. You stated that the requested grab bars are for safety and to prevent future injuries.The Plan denied your request. The Plan says this item is not a covered benefit.The Plan covers all items that Medicare covers. Medicare rules state that grab bars are not covered because they are not primarily medical in nature. While a grab bar may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item.Therefore, we decided that the Plan does not have to pre-approve a grab bar.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous positive airway pressure device and humidifier.You asked the Plan to pre-approve a continuous positive airway pressure device and humidifier. You say that the enrollee needs a CPAP.The Plan denied your request. The Plan says the enrollee's sleep study was done more than a year ago without any physician follow-up.The Plan must follow Medicare rules. The rules say that for any item to be covered by Medicare it must meet all applicable Medicare statutory and regulatory requirements.We looked at the file and Medicare rules. There is no current documentation supporting medical necessity. Based on this information, we decided that Medicare rules for coverage of a continuous positive airway pressure device and humidifier have not been met.Therefore, we decided that the Plan does not have to pre-approve a continuous positive airway pressure device and humidifier.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) admission.

You asked the Plan to pre-approve the SNF admission. You say that the enrollee needs more services than what she is receiving. The current care facility is not providing enough exercise to build her strength so she could return home. The Plan denied your request. The Plan says the enrollee does not meet the Medicare medical necessity criteria for SNF 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 the SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing and skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis and does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.

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 SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) admission.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an external insulin pump.You asked the Plan to pre-approve the insulin pump. You say that the enrollee's C-peptide level has been trending down and she would benefit from the use of a pump to obtain blood sugar control.The Plan denied your request. The Plan says the criteria for the requested pump are not met.The Plan follows Medicare rules. Medicare rules say that insulin pumps are covered for enrollees when C-peptide and blood glucose values are within the above described range. 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 insulin pump. Our reviewer says that the Medicare criteria for coverage of the insulin pump are not met. Our physician reviewer found in this case, the C-peptide would need to be less than 1.6 (it is 3.16) and the glucose level would need to be less than 225 (it is 342). This indicates that the criteria for pump use are not met. Although the pump may be beneficial as argued by the provider, Medicare does not provide coverage for insulin pumps in this situation.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 insulin pump have not been met.Therefore, we decided that the Plan does not haveto pre-approve an external insulin pump.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for additional routine transportation trips beyond the 50 one-way trips for 2019.You asked the Plan to provide coverage for additional routine transportation trips. You say that you need more than 50 non-emergent transportation trips for 2019 due to limited transportation access.The Plan denied your request. The Plan says transportation benefits beyond 50one-way trips are not a covered benefit.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 50 one-way trips per year. We looked at your request, the records in the case file, and the rules. The file shows that at the time of your appeal, you had used 47 of the 50 routine transportation trips for 2019. Routine transportation trips beyond 50 one-way trips is not a covered benefit. Therefore, we decided that the Plan does not have to provide coverage for additional routine transportation trips beyond 50 one-way trips for 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the upper and lower complete denture.

You asked the Plan to pre-approve the upper and lower complete denture. You say that you do not have any teeth. You say that due to this situation you cannot work. The Plan denied your request. The Plan says these are not covered benefits.

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 upper and lower complete denture.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 20.5 hours per week of personal attendant services.
You asked the Plan to pre-approve the personal attendant services. You say that everyday activities irritate your
condition and without assistance, your condition will worsen. The Plan denied your request. The Plan says the
services of a home health aide are not medically necessary.
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.
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 personal attendant services. Our
reviewer says that you do not meet Medicare coverage criteria for these services. Our physician reviewer found
the documentation does not reveal that you are homebound with leaving the home being a significant and
taxing effort. You do not require skilled therapy services, therefore; you do not require a home health aide.
Your Personal Attendant Services Assessment Tool did not indicate that you require a personal care attendant
for the treatment of your illness or injury.
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 personal attendant services have not been met. Therefore, we decided that
the Plan does not have to pre-approve 20.5 hours per week of personal attendant services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an in-network exception to be provided by out of network provider. You asked the Plan to pre-approve these out-of-network services. You say that you would like the plan to reconsider their decision.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.While you may receive services from the out-of-network provider, your cost share amounts will be higher. Therefore, we decided that the Plan does not have to pre-approve an in-network exception to be provided by out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lower extremity prosthesis additions; shank foot system with vertical loading pylon (L5987) and multi-axial rotation unit (L5986).You asked the Plan to pre-approve the lower extremity prosthesis additions. You say that the enrollee is very active and often encounters uneven terrain, ramps, and slopes. The Plan denied your request. The Plan says the additions are not medically necessary. The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the lower extremity prosthesis additions. Our reviewer says that the requested items are not considered medically reasonable and necessary in this case. Our physician reviewer found based on the medical records provided the enrollee does not meet the requirements for the requested lower extremity prosthesis additions (L5987 & L5986). 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 lower extremity prosthesis additions have not been met. Therefore, we decided that the Plan does not have to pre-approve lower extremity prosthesis additions; shank foot system with vertical loading pylon (L5987) and multi-axial rotation unit (L5986).
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve toe surgery services.You asked the Plan to pre-approve the requested services. You say that you are having a lot of pain with the great toe.The Plan denied your request. The Plan says that correcting the hallux valgus partially through the IP joint only may cause increased pressure on the great toe.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. The file shows that arthrodesis, great toe; interphalangeal (IP) joint (CPT Code 28755) was requested. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the requested services. Our physician reviewer found that you present with a 2-year history of chronic right great toe ulcer due to yourhallux valgus,and use of a carbon fiber AFO brace for yourfoot drop. You havenumbness of the foot and lacks distal motor function. You arestatuspost childhoodbilateral hind footreconstructions with Achilles tendon lengthening. Clinical exam findings document valgus and flexion at her right hallux IP joint, significant laxity of the hallux IP joint, and chronic-appearing superficial ulcer over the plantar medial aspect of the hallux IP joint. Surgery has been requested to include right hallux interphalangeal realignment arthrodesis to get you out of valgus and flexion,and to supinate the toe through the IP joint to take the pressure off this ulcer and allow it to heal. Evidence based medical literature generally supports surgical intervention for hallux IP joint laxity, deformity and pain. Given your neurologic deficits and IP joint deformity, laxity and pain, surgical intervention is reasonably indicated to address the chronic ulcer and stabilize the joint. Therefore, this request for great toe IP joint arthrodesisis medically reasonable and 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 requested services have been met.Therefore, we decided that the Plan has to pre-approvetoe surgery services.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: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve a hypoglossal nerve stimulator (64568) and a chest wall respiratory sensor (0466T).You asked the Plan to pre-approve the hypoglossal nerve stimulator and a chest wall respiratory sensor. You say that this service is medically necessary. The Plan denied your request. The Plan says thatthe hypoglossal nerve stimulator and a chest wall respiratory sensor are considered experimental/investigational.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 thecase file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the hypoglossal nerve stimulator and a chest wall respiratory sensor. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found the hypoglossal nerve stimulator is the most appropriate procedure and implant for you considering potential benefits and harms. Based on the high-quality evidence publishedacross different specialties, the hypoglossal nerve stimulator device should not be considered investigational or experimental. There is long-term data that shows a reduction in the severity of OSA, good patient compliance, a reduction in sleepiness, and improvement in quality of life.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 hypoglossal nerve stimulator and a chest wall respiratory sensor have been met. Therefore, we decided that the Plan has to pre-approve a hypoglossal nerve stimulator (64568) and a chest wall respiratory sensor (0466T). If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again ifwe 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 providea Group 3 power wheelchair with power tilt and recline.You asked the Plan to providea Group 3 power wheelchair with power tilt and recline. You say that your current power wheelchair is becoming inoperableand this would be your only mode of transportation.The Plan denied your request. The Plan says it is not clear from the notes if you can perform a weight shift to alleviate pressure.The Plan must follow Medicare rules. The rules say thatpower tilt and recline will be covered if a specialty evaluation was performed and you are at high risk for a pressure ulcer, utilize bladder management, or the seating system is needed to manage tone or spasticity. 
The file does not show that you meet the criteria for power tilt and recline. Therefore, we decided that the Plan does not have to provide a Group 3 power wheelchair with power tilt and recline.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approveInflectra.You asked the Plan to pre-approveInflectra. You say that the requested Inflectra is medically necessary.The Plan denied your request. The Plan says the enrollee must try and fail the plan's preferred drugs, leflunomide, sulfasalazine, or methotrexate first.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 carefullyreview the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Inflectra. Our reviewer says that the Plan's step therapy criteria have not been met. Our physician reviewer found the enrollee is with a diagnosis of arthropathic psoriasis, unspecified. The prior authorization request form documents that only Plaquenil (hydroxychloroquine) has resulted in treatment failure. The enrollee denied ever being on other DMARDs besides Plaquenil. The documentation does not support that leflunomide, sulfasalazine, or methotrexate would likely be less effective, and/or would likely have adverse effects 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 Inflectra have not been met.Therefore, we decided that the Plan does not have to pre-approveInflectra
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe power scooter (K0800).You asked the Plan to pre-approvethe power scooter. You say that you could walk short distances but cannot tolerate walking for a long period of time and would like the scooter approved so you can be able to get around.The Plan denied your request. The Plan says the request for a power scooter is not medically necessary.The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 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 power scooter. Our reviewer says that a power mobility device is not medically necessary. Our physician reviewer found the enrollee requires some supervision for transfers and gait, but is able to use a tripod cane. The records do not indicate that a lesser device such as a walker or cane could not safely address mobility 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 the power scooter have not been met.Therefore, we decided that the Plan does not have to pre-approvethe power scooter (K0800).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Yutiq (J7314). You asked the Plan to pre-approve Yutiq. You say that Yutiq is medically necessary for the enrollee. The Plan denied your request. The Plan says retinal vasculitis is a non-medically accepted indication.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 Yutiq. Our reviewer says that the documentation does not support that Yutiq is medically reasonable and necessary for the member. Our physician reviewer found the corticosteroid drug Ozurdex (dexamethasone) has been maintaining quiescence.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Yutiq have not been met. Therefore, we decided that the Plan does not have to pre-approve Yutiq (J7314).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a grab bar.You asked the Plan to pre-approve a grab bar. You say that you need the requested bars for the shower due to your conditions. You say that you are at risk fora fall and your physical therapist determined that the shower bars are necessary for you.The Plan denied your request. The Plan says this item is not a covered benefit.The Plan covers all items that Medicare covers. Medicare rules state that grab bars are not covered because they are not primarily medical in nature. While a grab bar may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item.Therefore, we decided that the Plan does not have to pre-approve a grab bar.