Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan
denied your request. The Plan says that that you can safely receive the services you need in other settings.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or
payment.

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. The Plan has not provided any medical records. Without medical records we are
unable to substantiate their medical necessity denial. Therefore, we decided that the Plan has to pre-approve
acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6530.
You asked the Plan to pre-approve the compression stockings. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are noncovered because they do not meet the statutory definition of a surgical dressing. Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6530.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the therapeutic continuous glucose monitor.
You asked the Plan to pre-approve the therapeutic continuous glucose monitor. You say that although you do
not qualify for the service under Medicare guidelines, you would like the Plan to cover this service. The Plan
denied your request. The Plan says you do not meet criteria for therapeutic continuous glucose monitors.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based
on the blood glucose testing results.
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood
glucose testing at least four times per day and does not use insulin with at least three daily injections. Based on
this information, we decided that Medicare rules for coverage of the therapeutic continuous glucose monitor
have not been met. Therefore, we decided that the Plan does not have to pre-approve the therapeutic continuous
glucose monitor.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a computed tomography (CT) colonography.
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 services are not covered.
The Plan must follow Medicare rules. The rules say that CT colonography is non-covered for colorectal cancer screening. We looked at the file and Medicare rules. The requested services are a CT colonography. These services are not covered by Medicare for colorectal cancer screening. Therefore, we decided that the Plan does not have to pre-approve a computed tomography (CT) colonography.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the bone replacement graft for ridge preservation
(D7953 x 2).

You asked the Plan to pre-approve the dental service. You say that the services are necessary. The Plan denied
your request. The Plan says bone replacement graft is not listed as 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 Plan does not have to pre-approve the
bone replacement graft for ridge preservation (D7953 x 2).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve diagnostic medial branch blocks (MBBs).
You asked the Plan to pre-approve the MBBs. The Plan denied your request. The Plan says this is not medically necessary.
The Plan follows Medicare rules. Medicare rules say that MBBs are covered for the indications in the LCD. 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 MBBs. Our reviewer says that the requested diagnostic MBBs are not medically reasonable and necessary. Our physician reviewer found that the LCD precludes performing diagnostic MBBs when there are other clear pain generators present. The current request is not considered 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 MBBs have not been met. Therefore, we decided that the Plan does not have to pre-approve diagnostic medial branch blocks (MBBs).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) coverage after February 26, 2021.
You asked the Plan to pre-approve continued SNF coverage. 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. 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 continued SNF coverage. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee received physical therapy and occupational therapy in the skilled nursing facility. The enrollee had difficulty with ambulation due to orthostatic hypotension. The enrollee required varying assistance with activities of daily living. The documentation does not support that the enrollee requires the specialized skills, knowledge, or judgment of a skilled professional nurse or qualified therapist to safely and effectively provide medically necessary and reasonable treatment. The documentation does not support that skilled nursing or skilled therapy services are required on a daily basis. As a practical matter, the enrollee no longer requires the necessary services on an inpatient basis, at a SNF level of care.
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 SNF coverage have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) coverage after February 26, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa.

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 pain related to bilateral
knee osteoarthritis, confirmed on imaging studies. She has not tried and failed the Plan's required drugs of
Orthovisc and Monovisc. The records do not show that the required drugs would be contraindicated or less
effective; therefore, the Euflexxa is not reasonable or 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 Euflexxa.
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 you don't meet criteria for coverage.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. 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: 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 would like reconsideration because these orthopedic soles will help re-balance your walk and give your foot an ankle support following surgery. 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 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-approve an over denture (D5863).
You asked the Plan to pre-approve the dental service. You say that the service is necessary. The Plan denied your request. The Plan says over denture is not listed as 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 Plan does not have to pre-approve an over denture (D5863).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Superion interspinous spacer (Vertiflex device).
You asked the Plan to pre-approve the Vertiflex device. You say that as the enrollee's treating physician, you believe that Superion spacing device and this choice meets the requirements as being reasonable and medically necessary. The Plan denied your request. The Plan says this is considered experimental and investigational and has not been shown to be safe and effective.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The rules also say that experimental and investigational devices are not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Vertiflex device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Superion interspinous spacer (Vertiflex device).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a incisional biopsy of oral tissue (D7286).
You asked the Plan to pre-approve the dental service. You say that the service is necessary as you are afraid
that the growth could be cancerous. You say that although dentures are not covered by your plan, the removal
of this growth is imperative in order to mold an accurate casting. The Plan denied your request. The Plan says
incisional biopsy of oral tissue 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. Additionally, the Evidence of Coverage clearly states that any services
not listed are not covered. Therefore, we decided that the Plan does not have to pre-approve a incisional biopsy
of oral tissue (D7286).
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a magnetic resonance imaging (MRI) of the abdomen (74183).
You asked the Plan to pre-approve an MRI. You say that the enrollee needs this service. The Plan denied your request. The Plan says that this is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve an MRI. Our reviewer says that the requested MRI is medically necessary. Our physician reviewer found an MRI with multiphase enhancement of the liver can be performed using a gadolinium-based contrast agent (GBCA), while lesion intensity on T1- and T2-weighted images helps identify specific lesions. Given this patient has cirrhosis and a liver lesion of 4.2 centimeters, the risk of malignancy is higher. 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 MRI have been met. Therefore, we decided that the Plan has to pre-approve a magnetic resonance imaging (MRI) of the abdomen (74183).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0676).

You asked the Plan to pre-approve a pneumatic compression device. You say that this is medically necessary.
The Plan denied your request. The Plan says this is not a covered benefit.

The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the
purpose of prevention of venous thromboembolism (E0676) is a preventive service.

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, this item is not a covered benefit of Medicare or the Plan.
This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided
that the Plan does not have to pre-approve a pneumatic compression device (E0676).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics provided by the physician.

You asked the Plan to pre-approve foot orthotics. You say that you have pain when walking and the cortisone
injection did not help. 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 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 provided by the physician.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lower partial denture with a flexible base (D5226).

You asked the Plan to pre-approve the dental item. You say that the enrollee does not have any molars as well as other teeth left in her mouth. You say that you will be extracting teeth # 27 and 29. You also say that the enrollee needs the partial denture in order to have chewing function. The Plan denied your request. The Plan says the lower partial denture with a flexible base is not listed as a covered service. The Plan also says that if a dental item or service is not listed in the benefit chart then it is 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 lower partial denture with a flexible base is 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 pre-approve a lower partial denture with a flexible base (D5226).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve six additional TMS therapy.

You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your
request. The Plan says the medical literature does not support the continuation of TMS when a good response is
achieved.

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 services. Our physician reviewer
found the enrollee must have a diagnosis of Major Depressive Disorder, Single Episode, Severe or Recurrent,
Severe. The enrollee's PHQ 9 score was 8 which is considered to be major depressive disorder, mild which
does not meet the criteria for the continuation of Transcranial Magnetic Stimulation (TMS).

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 pre-approve six additional TMS therapy.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core build up (D2950) for teeth # 17 and 20, pontics (D6242) for teeth # 18 and 19, and retainer crowns (D6752) for teeth # 17 and 21.

You asked the Plan to pre-approve the dental services. You say that you received a bridge in 2019 that did not fit properly. You say that it hurt you when you chewed. You say that you went back to get it adjusted several times. You say that the dentist dropped you as a patient. You say that the new dentist believes you need a new bridge. You say that you have holes in your mouth and are in great discomfort. The Plan denied your request. The Plan says bridges and other restorative services are covered 1 procedure per tooth every 5 plan years. The Plan also says that the frequency limit for these services have been exceeded.

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 frequency limit for these services have been exceeded. The record shows that the Plan paid for core build up for tooth # 17, retainer crowns for teeth # 17 and 21, and pontics for teeth # 18 and 19 that you received on May 24, 2018. The record also shows that the Plan paid for core build up for tooth # 20 that you received on March 2, 2018. Therefore, we decided that the Plan does not have to pre-approve core build up (D2950) for teeth # 17 and 20, pontics (D6242) for teeth # 18 and 19, and retainer crowns (D6752) for teeth # 17 and 21.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Resmed AirSense 10 continuous positive airway pressure (CPAP) machine.

You asked the Plan to pre-approve a Resmed AirSense 10 CPAP machine. You say that the enrollee needs to be treated with a CPAP device. The Plan denied your request. The Plan says the requested device is not from a Plan-preferred brand.

The Plan must follow Medicare rules. Medicare rules say that MA plans may specify brands and manufacturers as preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred brands and manufacturers. 

We looked at the file and Medicare rules. There is no medical reasoning in the submitted documentation detailing why a preferred brand will not meet the enrollee's needs. Based on this information, we decided that Medicare rules for coverage of a Resmed AirSense 10 CPAP machine have not been met. Therefore, we decided that the Plan does not have to pre-approve a Resmed AirSense 10 continuous positive airway pressure (CPAP) machine.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide a therapeutic continuous glucose monitor.

You asked the Plan to provide a therapeutic continuous glucose monitor. You say that testing is painful and
difficult. The Plan denied your request. The Plan says you do not meet criteria for a CGM.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based
on the blood glucose testing results.

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 therapeutic
continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to provide a
therapeutic continuous glucose monitor.