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

We decided that the Plan does not have to pre-approvean excision/transposition of pterygium with graft.You asked the Plan to pre-approvethe pterygium surgery. You say that this service is necessary due to symptoms of blurry vision.The Plan denied your request. The Plan says there has been no documentation conservative measures for this condition and there is inadequate evidence of visual interference.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 pterygium surgery. Our reviewer says that the requested procedure is not considered medically reasonable and necessary in this case. Our physician reviewer found on 10/28/19, it is documented that the enrollee has a history of pterygium bilaterally, as well as bilateral narrow angles. He complained of eye irritation. Examination of the right eye demonstrated a 2 mm nasal pterygium with injection/thickening across the limbus. A 1 mm pterygium was noted on the left eye. No treatment is necessary for pterygium in most cases. Occasionally, the growth of a pterygium will threaten to interfere with vision and may necessitate surgical excision. Surgery for pterygium is generally indicated when there is induced astigmatism that causes visual impairment, opacity in the visual axis, documented growth that is threatening to affect the visual axis via astigmatism or opacity, restriction of eye movement, or significant cosmetic impact or intractable irritation.There is a high recurrence rate, even when adjunctive measures are used with the excision. A recurrent lesion may be more inflamed or grow larger than the initial lesion. The available documentation in the case file does not support that this enrollee has a visually-significant pterygium or another accepted indication for pterygium excision. There is no documentation of failed medical therapy of the enrollee's symptoms.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 pterygium surgery have not been met.Therefore, we decided that the Plan does not have to pre-approve an excision/transposition of pterygium with graft.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued use of a continuous positive airway pressure device (CPAP) for the enrollee. You asked the Plan to pre-approve continued CPAP use. The Plan denied your request. The Plan says that the enrollee doesn't meet criteria for continued use of a CPAP. The Plan must follow Medicare rules. Medicare rules say that you must use the PAP 4 hours per night on 70% of nights during a consecutive thirty (30) day period anytime during the first three (3) months of initial usage.We looked at the file and Medicare rules. The compliance report included with the file indicates the enrollee did not adhere to therapy. Based on this information, we decided that Medicare rules for coverage of continued CPAP use have not been met. Therefore, we decided that the Plan does not have to pre-approve continued use of a continuous positive airway pressure device (CPAP) for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provideroutine transportation to appointments.You asked the Plan to provideroutine transportation to appointments. You say that you are unable to afford transport costs.The Plan denied your request. The Plan says non-emergency transportation by non-medical conveyances are not covered.The Plan must follow Medicare rules. Medicare does not cover transport in a vehicle that is not an ambulance. The Plan follows the same rule. We looked at your request, the records in the case file, and the rules. You do not have a Routine Transportation benefit. Based on this information, we decided that the Medicare rules for coverage of routine transportation to appointments have not been met.Therefore, we decided that the Plan does not have to provideroutine transportation to appointments.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) admission.
You asked the Plan to pre-approve the SNF admission. You say that you are in need of physical therapy for your left leg, which has lost all strength but is being denied due to the requirement of being hospitalized for 3 days. The Plan denied your request. The Plan says medical necessity cannot be established for SNF level of coverage.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing and skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis and does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) admission.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a maxillary partial denture and periodontal scaling & root planing on teeth #4-6 and #20-27 for the enrollee.
You asked the Plan to pre-approve these services. You say that The Plan denied your request. The Plan says that these services are not medically necessary.
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 these services when the services are medically necessary and reasonable. 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 these services are not medically reasonable and necessary for the enrollee in this case. The requested scaling and root planing is erroneously coded. D4342 should reflect 1-3 affected teeth in a quadrant, with four quadrants being present in the mouth, allowing for a maximum of four codes per patient at any one time. In any event,  the provider notes that consideration for scaling and root planing there must be periodontal charting supplied along with clear radiographs that could allow for visualization of bone loss around the affected teeth. As the necessary documentation has not been provided, and the coding is wholly incorrect, there is no medical necessity for the requested periodontal procedures. The upper partial denture is not medically necessary as the remaining upper teeth appear to be severely periodontally involved and are not favorable candidates for a metal based tooth borne appliance. There are no supporting teeth on the opposing side of the arch to stabilize an appliance, which would place excessive forces on the remaining teeth. The upper teeth appear to be subject to continuous deterioration and would not be adequate to support the requested appliance. A tissue borne all acrylic appliance may be a reasonable choice. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a maxillary partial denture and periodontal scaling & root planing on teeth #4-6 and #20-27 for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve nine additional physical therapy (PT) visits.
You asked the Plan to pre-approve the PT visits. The Plan denied your request. The Plan says the PT 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 the 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 when there is no change in the range of motion after an adequate number of sessions, skilled therapy is not effective. With home exercises and education to the enrollee, skilled therapy is not necessary. The requested therapies are for maintenance and specialized skills of a therapist are not required. 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 PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve nine additional physical therapy (PT) visits.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveEvenity injections.You asked the Planto pre-approvethe Evenity injections. You say that this should be allowed to treat his osteoporosis.The Plandenied your request. The Plansaysthis is not supported as safe in male patients due to the high incidence of cardiovascular events.The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Evenity injections. Our reviewer says that the requested medication is not considered medically reasonable and necessary. Our physician reviewer found there are no data in the Medicare-approved drug compendia, authoritative medical literature and/or accepted standards of medical practice showing safety and efficacy of Evenity for use in male patients -the drug cannot be considered medically reasonable and necessary based on current literature and standards of practice.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 Evenity injections have not been met.Therefore, we decided that the Plandoes not haveto pre-approveEvenity injections
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe Prevnar 13 vaccine for the enrollee.You asked the Plan to pre-approvethe Prevnar 13 vaccine. 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 a covered benefit.In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the Prevnar vaccine. The Plan follows the same rules. Records do not show that the enrolleehasbeen injured or directly exposed to any illness related to the Prevnar vaccine.We note that the plan will pay for this vaccine under the Part B benefits, however, this service must be given in the doctor's office setting.Therefore, we decided that the Plan does not have to pre-approvethe Prevnar 13 vaccine.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc-One Syringe medication.
You asked the Plan to pre-approve this medication. You say that you are requesting reconsideration of the Plan's denial as the enrollee has osteoarthritis of the left knee. The Plan denied your request. The Plan says there was no evidence that the enrollee had tried and failed a trial of Orthovisc and Monovisc medications. The Plan also indicates that it is not documented that the Orthovisc and Monovisc medications would not be as effective or would have adverse effects. The step therapy criteria have not been 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 this medication. Our reviewer says that the patient does not meet criteria for the Synvisc-One Syringe medication. Our physician reviewer found the medical records provided do not indicate that the patient has tried and failed the required drugs. Additionally, the medical records do not indicate that the Plan's required drugs would likely be less effective and/or likely have adverse effects for the enrollee.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this medication have not been met. Therefore, we decided that the Plan does not have to pre-approve Synvisc-One Syringe medication.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an inpatient admission for a total right knee replacement surgery.
You asked the Plan to pre-approve the inpatient admission. You say that you are requesting reconsideration of the Plan' denial. The Plan denied your request. The Plan says the inpatient admission is not medically necessary. An observation level of care is used to provide initial treatment while allowing the doctor to monitor the patient's health condition.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 inpatient admission. Our reviewer says that the patient does not meet criteria for coverage of an inpatient admission for a total right knee replacement surgery. Our physician reviewer found there was no documentation provided necessitating inpatient level of care services for the total knee replacement surgery. The procedure can be performed at an outpatient or inpatient level of care. An inpatient level of care can be requested post-procedure and will be reviewed at that time and determined based on the outcome and post-operative course. The review has determined that the patient does not require medically necessary hospital care expected to span 2 or more midnights.
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 inpatient admission have not been met. Therefore, we decided that the Plan does not have to pre-approve an inpatient admission for a total right knee replacement surgery.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve power seat elevation feature (E2300) and power standing feature (E2301) and cushion liner (K0108).
You asked the Plan to pre-approve power seat elevation, power standing feature and cushion liner. You say that you suffer from quadriplegia due to multiple sclerosis. You are short and you cannot perform daily functions without the seat elevator. The Plan denied your request. The Plan says these items are not primarily medical in nature.
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 power seat elevation feature (E2300) and power standing feature (E2301) and cushion liner (K0108).
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 because of your right foot condition you need orthotics.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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral.You asked the Plan to pre-approve these services. You say that you were diagnosed with prostate cancer and would like a further expert opinion.The Plan denied your request. The Plan says the tertiary level of care 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 these services. Our reviewer says that the tertiary level of care is not medically necessary. Our physician reviewer found the records show that you have been diagnosed with an elevated prostate specific antigen (PSA). There is no documentation of a diagnosis of complex prostate cancer that would require advanced diagnostic and therapeutic services that are only available at a tertiary care facility. Your condition can be adequately monitored by a non-tertiary urologist. The referral is 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 a referral.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve orthopedic heel lift (L3320).You asked the Plan to pre-approve orthopedic heel lift. You say that after spinal reconstruction in 2013, you were left with leg length discrepancy and now need a shoe lift in every right shoe. You cannot afford to buy shoes and get a lift put on anymore.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 orthopedic heel lift (L3320).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve So Clean CPAP cleaning solution (E1399).You asked the Plan to pre-approve CPAP cleaning solution. You say that you would like approval of the So-Clean solution to clean your CPAP machine to prevent infection and sickness.The Plan denied your request. The Plan says this item is a convenience item and is not primarily used to treat a medical condition, so therefore is not covered.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 So Clean CPAP cleaning solution (E1399).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe crown and root canal.You asked the Plan to pre-approvethe crown and root canal. You say that the tooth is causing you a lot of pain. You say that you cannot afford to pay.The Plan denied your request. The Plan says these are not covered benefits.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approvethe crown and root canal.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approveoral surgery (D7970), removal of torus mandibularis (D7473), removal of torus palatinus (D7472), and a hospital call (D9420).You asked the Plan to pre-approvethe dental services. You say that you are experiencing extreme pain in your gums. You say that you need the surgery because your gums are too flabby for a partial denture.The Plan denied your request. The Plan says the requested services are not listed as 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 services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approveoral surgery (D7970), removal of torus mandibularis (D7473), removal of torus palatinus (D7472), and a hospital call(D9420)