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

We decided that the Plan does not have to pre-approve periodontal scaling and root planning.

You asked the Plan to pre-approve periodontal scaling and root planning (D4341). You say that the enrollee needs these dental procedures. The Plan denied your request. The Plan says limitation was met.

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 services would exceed the benefit. Therefore, we decided that the Plan does not have to pre-approve periodontal scaling and root planning.
Appeal type: Outpatient Therapies
Decision: Favorable

We decided that the Plan has to pre-approve proton beam therapy.

You asked the Plan to pre-approve proton beam therapy. You say that the medical records provided support the need for the requested treatment. The Plan denied your request. The Plan says that research studies have found a lack of proof that routine use of the requested type of treatment would improve the outcome for the enrollee's cancer type.

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 proton beam therapy. Our reviewer says that proton beam therapy is considered medically reasonable and necessary in this case. Our physician reviewer found proton radiation reduces the dose to normal tissues by allowing for more precise dose delivery because of the unique physical properties of heavy particles. Protons penetrate tissue to a variable depth, depending upon their energy, and then deposit that energy in the tissue in a sharp peak. This allows the area to be re-irradiated. This enrollee has limited treatment options due to prior photon radiation. Studies have shown efficacy of photon therapy in vulvar cancer.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of proton beam therapy have been met. Therefore, we decided that the Plan has to pre-approve proton beam therapy.

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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that the enrollee is ready for transfer and that the records provided support the need for IRF care. The Plan denied your request. The Plan says the guidelines for coverage have not been met. The Plan says that the enrollee can safely receive the services needed in another setting.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for a hip fracture after a fall. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a whirlpool tub for the enrollee.

You asked the Plan to pre-approve the tub. 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 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 a whirlpool tub for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation of a nontoxic multinodular goiter (60699).

You asked the Plan to pre-approve radiofrequency ablation. You say that after considering the enrollee's imaging and adamant refusal of surgery, consensus was that percutaneous ablation was the most appropriate treatment option. The Plan denied your request. The Plan says this procedure is considered investigational and not medically necessary.

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 radiofrequency ablation have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation of a nontoxic multinodular goiter (60699).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6533.

You asked the Plan to pre-approve the compression stockings. You say that you need compression stockings. The Plan denied your request. The Plan says compression stockings are not covered by Medicare or the Plan.

The Plan must follow Medicare rules. The rules say that compression stockings described by code A6533 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 A6533.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110).

You asked the Plan to pre-approve the services. You say that you lost her dentures. The Plan denied your request. The Plan says the requested 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. The Plan covers dentures once every five years.

Dentures were last received less than five years ago. 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-approve a complete maxillary denture (D5110).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve miscellaneous DME supply, PureWick urine collection system (A0999).

You asked the Plan to pre-approve PureWick urine collection system. You say that you are request reconsideration for a Purwick urine collection system. The Plan denied your request. The Plan says this item is not a Medicare 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 miscellaneous DME supply, PureWick urine collection system (A0999).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the surgical placement of an implant body (D6010 x 2), bone graft at the time of implant placement (D6104), collection and application of autologous blood concentrate product (D7921), therapeutic parenteral drugs (D9612), and guided tissue regeneration (D4266).

You asked the Plan to pre-approve the dental services. You say that you need the grafting and implants. You say that you need these services in order to prevent further severe bone loss. You also say that these services will improve your ability to chew food. The Plan denied your request. The Plan says the requested dental services are not listed as covered services.

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 surgical placement of an implant body (D6010 x 2), bone graft at the time of implant placement (D6104), collection and application of autologous blood concentrate product (D7921), therapeutic parenteral drugs (D9612), and guided tissue regeneration (D4266).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and accessory (E0668).

You asked the Plan to pre-approve a pneumatic compression device and accessory. You say that you need this to treat your pain and swelling. The Plan denied your request. The Plan says the records do not show that you have had an adequate four-week trial of a basic device.

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 you 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 accessory (E0668).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve moderate intravenous sedation.

You asked the Plan to pre-approve anesthesia for diagnostic or therapeutic nerve blocks and injections (when block or injection is performed by a different physician or other qualified health care professional); other than the prone position (01991) and Anesthesia for diagnostic or therapeutic nerve blocks and injections (when block or injection is performed by a different physician or other qualified health care professional); prone position (01992). You say that you need the injection for pain relief. The Plan denied your request. The Plan says these injections are normally done without sedation.

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 anesthesia for diagnostic or therapeutic nerve blocks and injections (when block or injection is performed by a different physician or other qualified health care professional); other than the prone position (01991) and Anesthesia for diagnostic or therapeutic nerve blocks and injections (when block or injection is performed by a different physician or other qualified health care professional); prone position (01992). Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no indication for a separate anesthesia provider. Anesthesia is not medically reasonable or 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 anesthesia for diagnostic or therapeutic nerve blocks and injections (when block or injection is performed by a different physician or other qualified health care professional); other than the prone position (01991) and Anesthesia for diagnostic or therapeutic nerve blocks and injections (when block or injection is performed by a different physician or other qualified health care professional); prone position (01992) have not been met. Therefore, we decided that the Plan does not have to pre-approve moderate intravenous sedation.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve BRCA genetic screening testing.

You asked the Plan to pre-approve genetic testing. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of authorization for this testing is correct, because this testing is not covered.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. 

The test at issue in this appeal, genetic testing, is being requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pre-approve BRCA genetic screening testing.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve osseous surgery to be rendered by an OON provider.

You asked the Plan to pre-approve the osseous surgery. You say that you were not able to find a periodontist in your area. The Plan denied your request. The Plan says you have requested that this service be rendered by an OON provider. The Plan also says that you must receive services from a participating provider.

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 covered when they are received OON. The record shows that there are multiple in-network providers in your area who can treat you. Therefore, we decided that the Plan does not have to pre-approve osseous surgery to be rendered by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve medical nutrition therapy, initial assessment and intervention, each 15 minutes (97802) medical nutrition therapy re-assessment and intervention, individual, each 15 minutes (97803).

You asked the Plan to pre-approve medical nutrition therapy services. You say that the records provided should support the necessity of the service in dispute. The Plan denied your request. The Plan says this request is not covered as the enrollee does not have a diagnosis of diabetes or renal disease.

The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services only for enrollees with renal disease or diabetes. 

Records do not show that you suffer from renal disease or diabetes. Therefore, we decided that the Plan does not have to pre-approve medical nutrition therapy, initial assessment and intervention, each 15 minutes (97802) medical nutrition therapy re-assessment and intervention, individual, each 15 minutes (97803).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Superion interspinous spacer.

You asked the Plan to pre-approve a Superion interspinous spacer. The Plan denied your request. The Plan says this is 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 a Superion interspinous spacer. Our reviewer says that the requested Superion interspinous spacer is not considered medically reasonable and necessary in this case. Our physician reviewer found that the spacer device is experimental. More research is needed to show safety and efficacy of the 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 Superion interspinous spacer have not been met. Therefore, we decided that the Plan does not have to pre-approve a Superion interspinous spacer.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the supplemental benefits for the chronically ill.

You asked the Plan to pre-approve the supplemental benefits for the chronically ill. You say that you would like reconsideration because you have chronic conditions and are at a high risk of hospitalization. The Plan denied your request. The Plan says you do not have any of the listed chronic conditions for coverage.

Medicare does not offer a benefit to cover this service. The Plan offers supplemental benefits for the chronically ill. The Plan's rules apply in this case.

We looked at the file and rules. Based on this information, we decided that Medicare rules for coverage of the supplemental benefits for the chronically ill have not been met. Specifically, the record does not indicate that you have one of the covered conditions for approval of the Plan's supplemental benefit. Therefore, we decided that the Plan does not have to pre-approve the supplemental benefits for the chronically ill.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation feature (E2300) for the enrollee.

You asked the Plan to pre-approve the feature. 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 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 a power seat elevation feature (E2300) for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex Superion Spacer.

You asked the Plan to pre-approve the device. You say that you would like reconsideration because this device is medically necessary. The Plan denied your request. The Plan says this device is experimental.

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 device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this device is experimental and more research is needed to show its safety and efficacy. 

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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex Superion Spacer.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for moderate sedation services (99153).

You asked the Plan to pay for the moderate sedation services. You say that these services were medically necessary. The Plan denied your request. The Plan says this is a technical component only code and is not eligible for separate payment.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.

We find that CPT code 99153 is not supported in the medical record. Specifically, this code has a Professional Component (PC)/Technical Component (TC) Indicator of 3. This means that payment for this service is included in payment to the hospital. Based on this information, we decided that Medicare rules for coverage of the moderate sedation services have not been met. Therefore, we decided that the Plan does not have to pay for moderate sedation services (99153).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Purewick device station and accessories.

You asked the Plan to pre-approve incontinence supplies. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.

The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. 

The services at issue are a Purewick system and accessories, which are incontinence supplies. While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve a Purewick device station and accessories.