Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approveinpatient total knee replacement surgery.You asked the Plan to pre-approveinpatient total knee replacement surgery. You say that the services are necessary.The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not been met.The Plan must follow Medicare rules. Medicare rules say that items and services thatare 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 inpatient total knee replacement surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no specific medical comorbidity reported by the provider or documented in the submitted medical records to support the medical necessity of inpatient care for total knee replacement surgery. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of inpatient care over the outpatient observation level of care. Therefore, this request for inpatient total knee replacement is not medically reasonable and necessary.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rulesfor coverage of inpatient total knee replacement surgery have not been met.Therefore, we decided that the Plan does not have to pre-approveinpatient total knee replacement surgery.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician's services to be provided by the out-of-network provider.
You asked the Plan to pre-approve the physician's services. The Plan denied your request. The Plan says the service is available within the medical group network and your condition is not an emergency.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve physician's services to be provided by the out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6534.
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 A6534 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 A6534.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a mandibular partial denture (D5214).
You asked the Plan to pre-approve the mandibular partial denture. You say that your current partial does not fit properly. The Plan denied your request. The Plan says this service exceeds the maximum count allowed per period.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, mandibular partial denture (D5214) is limited to one procedure every five plan years. The record shows that you received a mandibular partial denture on May 10, 2019, and your mandibular partial denture (D5214) benefit has been exhausted. Therefore, we decided that the Plan does not have to pre-approve a mandibular partial denture (D5214).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve fluoride carries.

You asked the Plan to pre-approve the dental service. You say that the Plan has always covered this service for
other patients. You also say that the service is considered medical, not dental, due to the enrollee's diagnosis
and treatment. The Plan denied your request. The Plan says the dental treatment is not related to extraction
prior to radiation or a facial fracture.

Medicare generally does not cover dental services. The Plan follows the same rule.

Although the Plan offers a dental benefit in excess of Medicare coverage, the services you are asking the Plan
to pre-approve involve the care, treatment, filling, removal or replacement of the enrollee's teeth or the
structures directly supporting the enrollee's teeth. These are dental services that are not covered or paid for by
Medicare. Therefore, we decided that the Plan does not have to pre-approve fluoride carries.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xiidra eye drops.

You asked the Plan to pre-approve Xiidra eye drops. You say that this is the most effective medication. The
Plan denied your request. The Plan says coverage of this medication is the responsibility of the enrollee's
prescription drug plan.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered
drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Xiidra eye drops.

Benefits for Xiidra eye drops may be available under Medicare Part D. Contact the Plan that administers Part D
benefits for further information concerning any benefits and appeal rights.
Sincerely,
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveadditional routine transportation trips.You asked the Planto pre-approvethe additional trips. You say that this is medically necessary.The Plandenied your request. The Plansaysthe evidence shows that all of the trips have been used.Medicare does not covertransport 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 20 one-way trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation.Therefore, we decided that the Plandoes not haveto pre-approveadditional routine transportation trips.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips.
You asked the Plan to pre-approve the additional trips. You say that the enrollee has difficulty with ambulation,
and is a fall risk. The Plan denied your request. The Plan says the benefit has been exhausted.
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 60 one-way trips per year.
We looked at your request, the records in the case file, and the rules. Based on this information, we decided
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we
decided that the Plan does not have to pre-approve additional routine transportation trips.
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 have a leg length discrepancy and need customized orthopedic footwear. 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex Superion interspinous device for the
enrollee.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your
request. The Plan says medical studies have not proven that this device is helpful for treatment of the health
problem.
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 device is 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 the device have not been met. Therefore, we decided that the Plan does not have
to pre-approve the Vertiflex Superion interspinous device for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea single metal-ceramic crown restoration that is retained, supported and stabilized by an implant (D6066).You asked the Plan to pre-approvethe implant supported crown represented by code D6066. You say that the provider is a member of the plan. You say that you have been approved for cleanings and x-rays with this provider.The Plan denied your request. The Plan says the service in dispute is not a covered benefit under your contract.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 decidedthat the Plan does not have to pre-approvea single metal-ceramic crown restoration that is retained, supported and stabilized by an implant (D6066).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an additional ten (10) PT visits.You asked the Plan to pre-approve an additional ten (10) PT visits. You say that the additionalPT visits are necessary as you wantto be able to walk again with the use of a cane. You say that currently you haveto use a roller walker but youcannot use the roller walker on surfaces that are not flat. The Plan denied your request. The Plan says PTfor multiple sclerosis is considered medically necessary when you need the skills of a physical therapist. Based on the clinical information provided to us, you had no changes in balance or leg strength. You had minimal improvement in the number of times you can stand up from sitting. The notes do not show you need the ongoing skills of a physical therapist since your condition does not appear to have the potential to improve.The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the additional ten (10) PT visits. Our reviewer says that skilled services are not medically reasonable and necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found that the requested additional PT therapy is not generally accepted as specific and effective therapy for your condition. You have had extensive therapy for this condition and itdoes not appear that you require the unique skills of a professional therapist to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or under the supervision of a therapist. You have been instructed in an independent exercise program. Thespecialized skill, knowledge and judgment of a qualified therapist is not required to establish, design and/or deliver a program to maintain your current condition or to prevent or slow further deterioration.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 additional ten (10) PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve an additional ten (10) PT visits.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveCequa solution.You asked the Plan to pre-approveCequa solution. You say that the enrollee's dry eyes have improved with this medication.The Plan denied your request. The Plan says coverage of this medication is the responsibility of the enrollee's prescription drug plan.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pre-approveCequa solution.Benefits for Cequa solutionmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve eight (8) additional PT visits.

You asked the Plan to pre-approve the eight (8) additional PT visits. You say that the enrollee has made great progress and will need additional PT to continue to make progress. The Plan denied your request. The Plan says there is nothing in the supplied documentation that supports the services will be of such a level of complexity and sophistication, or the condition of the patient will be such that the services required can be safely and effectively performed only by a qualified therapist or under a therapist's supervision vs a home exercise program.

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the eight (8) additional PT 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 requested additional PT therapy is not generally accepted as specific and effective therapy for the enrollee's condition. The enrollee has had extensive therapy for this condition and it does not appear that the enrollee requires the additional requested unique skills of a professional therapist to safely and effectively provide treatment or that the services can be safely and effectively performed only by a therapist, or under the supervision of a therapist. The enrollee has been authorized additional sessions to review an independent exercise program. The specialized skill, knowledge
and judgment of a qualified therapist is not required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration. 

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 eight (8) additional PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve eight (8) additional PT visits.,
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea bath/shower chair.You asked the Planto pre-approvethe chair. You say that this is medically necessary.The Plandenied your request. The Plansaysthis is not a covered benefit.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 Plandoes not haveto pre-approvea bath/shower chair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a disposable insulin delivery system (A9274).

You asked the Plan to pre-approve a disposable insulin delivery system. You say that this is medically necessary and you've been using it for years. The Plan denied your request. The Plan says this is not covered.

The Plan must follow Medicare rules. Medicare rules say that disposable drug delivery systems, including elastomeric infusion pumps are non-covered devices because they do not meet the Medicare definition of durable medical equipment. 

We looked at the file and Medicare rules. The item at issue is not covered by Medicare. Based on this information, we decided that Medicare rules for coverage of a disposable insulin delivery system have not been met. Therefore, we decided that the Plan does not have to pre-approve a disposable insulin delivery system (A9274).
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 the enrollee needs a
therapeutic continuous glucose monitor. The Plan denied your request. The Plan says the documentation does
not support the criteria.
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 does not indicate that the enrollee performs blood
glucose testing at least four times per day, uses insulin with at least three daily injections, or requires frequent
self-adjustment of insulin dosage based on the blood glucose testing results. 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.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a core buildup, including any pins when required (D2950).

You asked the Plan to pre-approve the core buildup. The Plan denied your request. The Plan says this 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 requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a core buildup, including any pins when required (D2950).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve fluoride carries (21089).

You asked the Plan to pre-approve the dental service. You say that the Plan has always covered this service for
other patients. You also say that the service is considered medical, not dental, due to the enrollee's diagnosis
and treatment. The Plan denied your request. The Plan says the dental treatment is not related to extraction
prior to radiation or a facial fracture. The Plan also says that fluoride carries are not a covered service.

Medicare generally does not cover dental services. The Plan follows the same rule.

Although the Plan offers a dental benefit in excess of Medicare coverage, the services you are asking the Plan
to pre-approve involve the care, treatment, filling, removal or replacement of the enrollee's teeth or the
structures directly supporting the enrollee's teeth. These are dental services that are not covered or paid for by
Medicare. Therefore, we decided that the Plan does not have to pre-approve fluoride carries (21089).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve immediate maxillary partial denture - cast metal
framework with resin denture bases (D5223).

You asked the Plan to pre-approve immediate maxillary partial denture - cast metal framework with resin
denture bases. You say that the service is medically necessary. The Plan denied your request. The Plan says the
service you received 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. This benefit includes the ADA
codes listed in your EOC.

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. Specifically, ADA code D5223 is not listed in the Plan's EOC as a
covered benefit. Therefore, we decided that the Plan does not have to pre-approve immediate maxillary partial
denture - cast metal framework with resin denture bases (D5223).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe complete lower denture (D1520).You asked the Plan to pre-approvethe denture. You say that due to surgery your dentures do not fit any moreThe Plan denied your request. The Plan says this request exceeds the benefit maximum of once every 5 years.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. This service is allowed once every 5 years. The records show that a full lower denture was already provided February 27, 2019. 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 at this time.Therefore, we decided that the Plan does not have to pre-approvethe complete lower denture (D1520).