Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea standard power operated vehicle and accessories.You asked the Plan to pre-approvea standard power operated vehicle and accessories. You say that you need a power operated vehicle because you are in daily pain that effects your ability to stand and walk.The Plan denied your request. The Plan says your assessment does not reveal deficits in MRADLsand there are nodescriptions of strength, ambulation,or balance.The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 
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 standard power operated vehicle and accessories. Our physician reviewer found the enrolleedoes not meet the requirement for a Group 1 standard power operated vehicle (K0800). The documentation indicates that the enrolleehas a personal mobility deficit but the documentation does not support that the enrollee is unable to performMRADLs in the home. The documentation does not indicate that the enrollee'smobility in the home is unable to be helped by a manual wheelchair.The enrolleewas noted to ambulate 75 feet in the clinic on September 4, 2019. Upper extremity Range of Motionand strength are normal. The documentation does not reveal a home assessment indicating that this PMD would be safe to use in the home.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 standard power operated vehicle and accessories have not been met.Therefore, we decided that the Plan does not have to pre-approvea standard power operated vehicle and accessories.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveDiclofenac Sodium 1% Gel.You asked the Plan to pre-approvethe Diclofenac Sodium. You say that the drug is medically necessary.The Plan denied your request. The Plan says coverage for Diclofenac Sodium is not available under the Part B medical benefit.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-approveDiclofenac Sodium 1% Gel.Benefits for the Diclofenac Sodiummay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Magnetic Resonance Imaging (MRI) of the Lumbar Spine (72148).You asked the Plan to pre-approve the MRI. You say that the MRI is medically necessary.The Plan denied your request. The Plan says the records provided do not support medical necessity of the MRI.The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the MRI. Our reviewer says that coverage criteria has not been met. Our physician reviewer found no detailed history regarding the back pain is noted. No focused examination of the back and/or relevant areas is noted. There is no evidence of attempted therapy, OTC or prescription. There is no documentation of response to attempted therapies. As such, the documentation does not support that the requested MRI of the lumbar spine is currently medically necessary or reasonable.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 MRI have not been met.Therefore, we decided that the Plan does not have to pre-approve Magnetic Resonance Imaging (MRI) of the Lumbar Spine (72148).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a removal of residual tooth roots (D7250) for teeth # 6, 7, 8, 10, 21, 23, 24, 25, and 26, the partial upper denture (D5214), and the partial lower denture (D5213). You asked the Plan to pre-approve the dental services. The Plan denied your request. The Plan says that the clinicals did not show that the enrollee's teeth were erupted or exposing the roots of the teeth in question. 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 the dental 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 the dental services. Our reviewer says that the requested dental services are not medically necessary. Our physician reviewer found the provided x-rays reveal that teeth # # 6, 7, 8, 10, 21, 23, 24, 25, and 26 are present in the dental arch. The code provided is reserved for removal of residual roots,which by its nature requires that an attempt to remove a tooth had been made and a root tip or portion of the root was retained in the alveolar bone. Therefore, in this case, as all noted teeth are present in the dental arches, the code provided is incorrect for the current condition. Additionally, requests for the partial dentures are not medically necessary as the teeth are still present without proper coding for removal.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.In this case, the CPT Code Manual definition of code D7250 is removal of residual tooth roots (cutting procedure).
We find that CPT code D7250 is not supported in the medical record. Specifically because the teeth in which this service has been requested for are still present in the dental arches with no proper coding for removal.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 the dental services have not been met.Therefore, we decided that the Plan does not have to pre-approve a removal of residual tooth roots (D7250) for teeth # 6, 7, 8, 10, 21, 23, 24, 25, and 26, the partial upper denture (D5214), and the partial lower denture (D5213)
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a 1mg Denosumab injection (J0897).
You asked the Plan to pre-approve the Denosumab. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation does not indicate that the member had failed IV bisphonates and their serum calcium is below the coverage threshold.
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 Denosumab. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this member has hypercalcemia unrelated to malignancy. She has renal function (an EGFR of 45) which is well within the acceptable range to use a biphosphonate. 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 Denosumab have not been met. Therefore, we decided that the Plan does not have to pre-approve a 1mg Denosumab injection (J0897).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Omnipod disposable insulin delivery systems.You asked the Plan to pre-approve Omnipod disposable insulin delivery systems. You say that you need the Omnipods on a continuous basis for your Omnipod insulin pump.The Plan denied your request. The Plan says Omnipods are not covered by Medicare because they do not meet the Medicare definition of durable medical equipment.The Plan must follow Medicare rules. Medicare rules say that disposable drug delivery systems do not meet the Medicare definition of durable medical equipment and therefore the drugs and supplies are also non-covered.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Omnipod disposable insulin delivery systems have not been met.Therefore, we decided that the Plan does not have to pre-approve Omnipod disposable insulin delivery systems.Please note, the Plan has submitted your request under your Part D benefits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable oxygen concentrator.You asked the Plan to pre-approve a portable oxygen concentrator. You say that your portable tanks are heavy and carrying them is a problem so you stay home most of the time.The Plan denied your request. The Plan says there is no documentation that the portable oxygen system does not meet your needs within your home.The Plan must follow Medicare rules. The rules say that to qualify for portable oxygen, the patient must meet the criteria for home oxygen. The documentation must show that the patient is mobile in the home and would benefit from the use of portable oxygen in the home. We looked at this the file and Medicare rules. The record shows that you have a stationary oxygen system with refillable portable tanks. This stationary oxygen system with refillable portable tanks meets your in-home needs and serves the same purpose as a portable oxygen concentrator. Medicare does not cover equipment for use outside the home. Based on this information, we decided that Medicare rules for coverage of a portable oxygen concentrator have not been met.Therefore, we decided that the Plan does not have to pre-approve a portable oxygen concentrator.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by out of network provider.You asked the Plan to pre-approve injections. You say that you would like this visit to be approved because they are the only ones who can do the injections you need.The Plan denied your request. The Plan says there are in-network providers available for the same 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 pre-approved care.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 out of network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Magnetic Resonance Imaging (MRI) of the Abdomen and Pelvis (74183).You asked the Plan to pre-approve the MRI. You say that the service is medically necessary due to elevated liver function tests.The Plan denied your request. The Plan says ultrasound is the standard of care. The MRI is not medically necessary.The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the MRI. Our reviewer says that the MRI is not medically necessary. Our physician reviewer found based on the medical records provided the abdominal MRI scan would not be medically reasonable and necessary as the initial evaluation of the abnormal liver functions tests in this case.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 MRI have not been met.Therefore, we decided that the Plan does not have to pre-approve Magnetic Resonance Imaging (MRI) of the Abdomen and Pelvis (74183).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approveperiodontal scaling and root planing for 1 to 3 teeth per quadrant (D4342) for all 4 quadrants.You asked the Plan to pre-approvethe dental services. You say that you have plaque and calcium build up. You say that the build up will start pushing against other teeth. You also say it will cause your teeth to shift out of place.The Plan denied your request. The Plan says periodontal services, including periodontal scaling and root planing is not covered by the Plan.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, periodontal scaling and root planing for 1 to 3 teeth per quadrant is not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approveperiodontal scaling and root planing for 1 to 3 teeth per quadrant (D4342) for all 4 quadrants.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea positron emission tomography (PET) scan with CT scan (CPT 78815).You asked the Plan to pre-approvethe PET scan. The Plan denied your request. The Plan says this is not medically necessary.The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Planwas correct in denying the request to pre-approve the PET scan. Our reviewer says that the requested PET scan is not medically reasonable and necessary. Our physician reviewer found that the enrollee has an early stage IB vulvar cancer diagnosed and treated in early 2018. She has no signs of recurrence on exam. A DVT was diagnosed in her lower extremity in October 2019. Although cancer can be a cause of a DVT, a PET scan is not the first test to screen for cancer. A CT scan or ultrasound would be preferred. A PET scan is not reasonable or medically necessary.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the PET scan have not been met.Therefore, we decided that the Plan does not have to pre-approvea positron emission tomography (PET) scan with CT scan (CPT 78815)
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea physician consultation for cataract surgery to be provided by the provider .You asked the Plan to pre-approvethe physician consultation. The Plan denied your request. The Plan says services with out-of-network providers are allowed only when the service is medically necessary but unavailable within the network or for emergency care.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 pre-approved care.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 the requested services.Therefore, we decided that the Plan does not have to pre-approvea physician consultation for cataract surgery to be provided by this out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cooled genicular nerve ablation to the left knee (64640).
You asked the Plan to pre-approve cooled genicular nerve ablation to the left knee. You say that this is
medically necessary to treat the enrollee's symptoms. The Plan denied your request. The Plan says this is an
experimental service.
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 cooled genicular nerve ablation to the
left knee. Our reviewer says that the requested services are not considered medically reasonable and necessary
in this case. Our physician reviewer found this is an experimental/ investigational procedure that is the subject
of on-going clinical trials. The patient is not enrolled in a clinical trial. Therefore, the requested procedure is
considered 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 cooled genicular nerve ablation to the left knee have not been met. Therefore,
we decided that the Plan does not have to pre-approve cooled genicular nerve ablation to the left knee (64640).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve out-of-network ophthalmology services. You asked the Plan to pre-approve the out-of-network ophthalmology services. You say that you have double vision and need to have strabismus surgery. You say that the surgery you need done has to be performed by a pediatric ophthalmologist, and that none of the plan's network providers are pediatric ophthalmologist. You say that the physician is the only provider that can perform the procedure.The Plan denied your request. The Plan says the services the enrollee requires are available through in-network providers. The plan says that a physician office has confirmed that he treats strabismus and double vision in adults.Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan providers available to meet enrollees' needs. Your contract with the Plan says that, with few exceptions, you must use contract providers for care.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 out-of-network ophthalmology services. Our reviewer says that the criteria for coverage of out-of-network care have not 
been met. Our physician reviewer found the treatment of the enrollee's diplopia with the non-network ophthalmologist is not medically necessary based on the lack of an initial ophthalmologic evaluation and the absence of a diagnosis for the diplopia. Our physician reviewer found that the enrollee's double vision can be adequately evaluated by the in-network health plan ophthalmologists. Our physician reviewer found that it is possible that the enrollee may need out-of-network care, but, since there is not yet a diagnosis for the cause of the diplopia, that would not be the first step in this case. Our physician reviewer found that the health plan has made good effort to ensure that there are appropriate providers available to treat the enrollee for his current needs.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 out-of-network ophthalmology services have not been met.Therefore, we decided that the Plan does not have to pre-approveout-of-network ophthalmology services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 2 retainer crowns anda pontic to be provided. You asked the Plan to pre-approve the retainer crowns and pontic. You say that you had an appointment for just a cleaning. You also say that you were told that you needed a crown because the ones on your left side are too old.The Plan denied your request. The Plan says these services are not covered under your benefit package.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-approve2 retainer crowns and a pontic to be provided.Your complaint about being charged for incorrect services and your treatment with Tera is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Rinvoq 15mg tablets.You asked the Plan to pre-approve Rinvoq. You say that the requested medication is medically necessary. The Plan denied your request. The Plan says Rinvoq is not eligible for coverage under the Part B medical benefit.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 Rinvoq 15mg tablets.Benefits for Rinvoqmay be available under Medicare Part D.Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute IRF admission and services.You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary. 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 IRF admission is not medically necessary without any other information and whether or not you meet the CMS criteria for IRF admission It can be determined if more information is provided.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-approveacute IRF admission and services.