Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vertiflex Superion Spacer Implantation.

You asked the Plan to pre-approve Vertiflex Superion Spacer Implantation. You say that the insertion of an interspinous process spacer device is covered by Medicare. The Plan denied your request. The Plan says a review of the current medical literature indicates this service is considered experimental and investigational.

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 Vertiflex Superion Spacer Implantation. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the device is experimental. More research is needed to show 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 Vertiflex Superion Spacer Implantation have not been met. Therefore, we decided that the Plan does not have to pre-approve Vertiflex Superion Spacer Implantation.
Appeal type: Supplemental Benefit
Decision: Unfavorable

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.

The rules say that Medicare will not pay for dental services. Dental services are items and services involving the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae, dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this rule in the SSA, Section 1862(a)(12) and Medicare Benefit Policy Manual, Chapter 15, Section 150.

If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.

The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract says that the Plan covers certain dental services as a supplemental (extra) benefit. The contract says prior authorization may be required. You can find this information on page 81 of the Plan's 2020 Evidence of Coverage (EOC).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional crown provided on December 19, 2019.

You asked the Plan to pay for the additional crown. You say that the 2019 booklet noted coverage for crowns. You say that you are requesting coverage based on the response indicating coverage for two crowns. The Plan denied your request. The Plan says the service is not a covered benefit.

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 Plan also had a maximum benefit of one crown per calendar year. The Plan paid for one crown provided on December 19, 2019, which exhausted your benefit. Therefore, we decided that the Plan does not have to pay for the additional crown provided on December 19, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ensure. 
 
You asked the Plan to pre-approve Ensure. You say that you would like the Plan to reconsider their denial. The 
Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation. 
 
The items you asked the Plan to pre-approve are nutritional supplements. Therefore, we decided that the Plan 
does not have to pre-approve Ensure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental crowns (D2740) on teeth # 24 and 25. 
 
You asked the Plan to pre-approve two dental crowns. You say that you would like the Plan to reconsider their 
denial. The Plan denied your request. The Plan says the services 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 dental crowns (D2740) 
on teeth # 24 and 25 are not covered at this time. The Plans supplemental dental benefit clearly covers up to 
two dental crowns per year. The file shows that you have already received a dental crown on tooth # 6 on 
January 7, 2020 and a dental crown on tooth # 9 on May 11, 2020. This means that you have exhausted your 
dental crown benefit for the 2020 benefit year. Therefore, we decided that the Plan does not have to pre-
approve dental crowns (D2740) on teeth # 24 and 25.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a removable under seat pouch. 
 
You asked the Plan to pre-approve a removable under seat pouch. You say that the enrollee needs an ultra-
lightweight wheelchair and accessories. The Plan denied your request. The Plan says a removable under seat 
pouch does not serve a medical purpose. 
 
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 removable under seat pouch.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out of 
network provider. 
 
You asked the Plan to pre-approve services with an out of network podiatrist. You say that you would like to 
continue care of this enrollee. The Plan denied your request. The Plan says there are in network podiatrists who 
can provide this service. 
 
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 
the medical services to be provided by an out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the alveoloplasty of three quadrants (D7311), the regional block anesthesia (D9211), and the therapeutic drug injection (D9610) requested along with approved dental extractions and deep sedation. You asked the Plan to pre-approve the alveoloplasties, regional block, and drug injection. You say that it is necessary for all of these services to be approved as you are not able to pay for them. The Plan denied your request. The Plan says all services eligible for coverage have been approved. Your plan does not pay for alveoloplasty, regional blocks, or drug injections under your dental benefit. 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 alveoloplasty of three quadrants (D7311), the regional block anesthesia (D9211), and the therapeutic drug injection (D9610) requested along with approved dental extractions and deep sedation.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that LTACH Admission is medically necessary. The Plan denied your request. The Plan says the enrollee can receive same services at the current level of care.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 

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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan. 

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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IKBKAP genetic testing (81260). You asked the Plan to pre-approve IKBKAP genetic testing. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says this service is not covered by Medicare or the Plan. The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. Medicare has determined that testing for the IKBKAP is not a Medicare benefit and is a statutorily excluded service. Therefore, we decided that the Plan does not have to pre-approve IKBKAP genetic testing (81260).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional physical therapy visits.
You asked the Plan to pre-approve additional physical therapy visits. You say that your neurologist ordered additional service units. You say that she wants you to continue therapy because your balance remains a serious issue. The Plan denied your request. The Plan says additional visits are not medically necessary.
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 additional physical therapy visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found that you had prior therapy for this condition and the already authorized additional sessions should be sufficient to review an independent exercise program. Our reviewer says that the unique skills of a professional therapist are not required to safely and effectively provide ongoing treatment.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of additional physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve additional physical therapy visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower commode chair (E1399).
You asked the Plan to pre-approve a shower commode chair. You say that the enrollee has ALS and cannot sit upright. She has lost her ability to hold her body up. She has to tilt back to be washed in the shower. This seat has a seat belt and can roll in the shower. The Plan denied your request. The Plan says this item is not covered.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair 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 shower commode chair (E1399).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional physical therapy visits.

You asked the Plan to pre-approve additional physical therapy visits. You say that therapy has significantly helped with symptoms. You say that you want to continue therapy to maximize the results of his physical therapy and advance him to a home program. The Plan denied your request. The Plan says additional visits are not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.

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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 additional physical therapy visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found that the enrollee has had extensive prior for this condition and was educated in an independent exercise program. Our reviewer says that the unique skills of a professional therapist are not required to safely and effectively provide ongoing treatment.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of additional physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve additional physical therapy visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the home automatic blood pressure monitor (A4670). 
 
You asked the Plan to pre-approve the home automatic blood pressure monitor. You asked to consider 
the purchase of a blood pressure monitor in lieu of the above consideration as well as hospital visits that may 
be avoided. The Plan denied your request. The Plan says this item is not covered because it is a precautionary 
device and does not treat a medical condition. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers home blood pressure monitors only 
for enrollees who are on home dialysis, or those who meet the criteria for white coat hypertension and require 
ABPM to confirm a diagnosis of hypertension.  
 
The records do not show that this monitor is requested in the setting of home dialysis services, or that this 
request is for evaluation of suspected white coat hypertension. Although monitoring blood pressure in the home 
may be appropriate in this case, neither Medicare nor the Plan provides coverage of this item in this situation. 
Therefore, we decided that the Plan does not have to pre-approve the home automatic blood pressure monitor 
(A4670).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation feature, push handles, bag hooks, 
and intelligent control system backrest mount for a power wheelchair. 
 
You asked the Plan to pre-approve power wheelchair options/accessories. You say that your current wheelchair 
is too old for repair and without a power wheelchair for mobility you would be totally bedridden. The Plan 
denied your request. The Plan says the denial of authorization for these features is correct, because these non-
standard upgrades are considered convenience items and are not covered. The Plan also says that they have 
approved coverage for the power wheelchair itself and all other requested features, so this denial is only for the 
requested power seat elevation feature, push handles, bag hooks, and backrest mount. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The items at issue in this appeal do not serve a purpose that is primarily medical in nature. These wheelchair 
features are used for comfort/convenience and are not covered by Medicare. Therefore, we decided that the 
Plan does not have to pre-approve a power seat elevation feature, push handles, bag hooks, and intelligent 
control system backrest mount for a power wheelchair.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you believe skilled nursing facility 
services will not be able to provide adequate care. The Plan denied your request. The Plan says the enrollee 
does not meet Medicare guidelines for a LTACH admission. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee was admitted to the current acute care hospital with tremors, acute 
on chronic kidney injury, and acute hypoxic respiratory failure secondary to atelectasis. She was treated with 
oxygen, BiPAP, CPAP, diuresis, and dialysis. Recent notes show that she is steadily improving, however, 
diarrhea was noted. The enrollee appears to be improving and only requires short term additional acute care 
services which can be completed at the current facility. The enrollee does not require services at the LTACH 
that are not already available and covered at the current facility. Therefore, this request for LTACH services 
will be considered not medically necessary at this time. Transfer to a lower level of care may be considered 
soon. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
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 IRF care is medically necessary. The Plan denied 
your request. The Plan says the guidelines for coverage of IRF care have not been met. The Plan says that the 
enrollee can safely receive services 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 above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve 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 do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for surgery for a perforated gastric ulcer. The enrollee's medical problems are stable and 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 does document a need for physical and occupational therapy, it does not document a 
need for an intensive rehabilitation program. 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: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve 17 further fractions. We decided that the Plan does not have to 
pre-approve six further fractions of IMRT, for a total of 23. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan says that 
28 fractions are approved and 23 further are not medically necessary. 
 
We decided that the Plan has to pre-approve 17 further fractions of IMRT.  
 
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 for these services. Our reviewer says that 17 further 
fractions are medically necessary. Our physician reviewer found that the enrollee has favorable intermediate 
risk prostate cancer. The use of 45 fractions of IMRT is considered acceptable per National Comprehensive 
Cancer Network (NCCN) guidelines. 45 fractions would be the standard of care for the enrollee's condition; 
therefore, 17 further fractions, for a total of 45, is reasonable and medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have been met. Therefore, we decided that the Plan has to pre-
approve 17 further fractions of IMRT. 
 
We also decided that the Plan does not have to pre-approve six further fractions of IMRT, for a total of 
23.. 
 
Our reviewer says that six further fractions, for a total of 23, are not 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 
six further fractions of IMRT, for a total of 23. 
 
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.