Persius/hicric huggingface dataset:
Appeal type: Surgery
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 want to see this provider. The Plan denied your request. The Plan says the services are available from network providers. 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 a referral.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea porcelain crown fused to predominantly base metal (D2751) for tooth # 18 to be provided by "the provider".You askedthe Plan to pre-approvethe dental service. You say that Parkway did bad dental work. You say that your crown has a hole. You also say that a dental office advised that it was done wrong and needs to be replaced.The Plan denied your request. The Plansays the frequency limit for a crown is once in a 5-year period. The Plan also says that the frequency limit for this service has been reached.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 and crowns are a covered service, the frequency limit has been reached. The record shows that you las received a crown for tooth # 18 on May 9, 2017.Therefore, we decided that the Plan does not have to pre-approvea porcelain crown fused to predominantly base metal (D2751) for tooth # 18 to be provided by "the provider".
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lower extremity prostheses Addition foot, flexible keel (L5972).
You asked the Plan to pre-approve Addition foot, flexible keel (L5972). You say that you need the foot, flexible keel because you are highly active. The Plan denied your request. The Plan says criteria for the foot, flexible keel has not been met. 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 Addition foot, flexible keel (L5972). Our reviewer says that the requested items are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee does not meet the requirement for lower extremity prostheses, foot, flexible keel (L5972). Under Local Coverage Determination (LCD): Lower Limb Prostheses (L33787) a flexible-keel foot (L5972) or multiaxial ankle/foot (L5978) is covered for enrollees whose functional level is 2 or above. The patient is noted to be a K1 household ambulator therefore the criteria for the L5972 has not been met.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Addition foot, flexible keel (L5972) have not been met. Therefore, we decided that the Plan does not have to pre-approve lower extremity prostheses Addition foot, flexible keel (L5972
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve weight loss surgery. You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your request. The Plan says that there is no evidence that after the first gastric surgery, you were able to keep the weight off, stick with a weight loss program, or that you could follow post-op instructions. The Plan must follow Medicare rules. Medicare rules say that Medicare covers gastric surgery under certain circumstances. 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 surgery. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found the requested procedure is one of the covered types of bariatric surgery procedures. Your BMI is 36.65. There are multiple obesity-related comorbid conditions, including diabetes mellitus and hyptertension. You continue to meet all CMS criteria for this surgery at this time.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 surgery have been met.Therefore, we decided that the Plan has to pre-approve weight loss surgery. If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe medical services to be provided by out of network provider, "the provider" .You asked the Plan to pre-approvephysical therapy. You say that the in-network provider is dangerous to get to and this provider knows how to treat your specific condition.The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this provider is out-of-network with the Plan and you can be treated within the Plan network.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 inthis 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-approvethe medical services to be provided by out of network provider, "the provider".
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe K3 prosthetic knee and advanced foot with K3 components to be provided.You asked the Plan to pre-approvethe K3 prosthetic knee and advanced foot with K3 components. You say that the goal of this prosthesis is to allow the enrollee to ambulate in a safe and effective manner so he can return to his previous level of mobility and activities of daily living.The Plan denied your request. The Plan says the requested K3 prosthetic knee exceeds the enrollee's need and does not meet the Medicare criteria of reasonable and 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 the K3 prosthetic knee and advanced foot with K3 components. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not indicate that the enrollee is a community ambulator who has the ability to traverse most environmental barriers and has vocational, therapeutic, or exercise activity that demands prosthetic utilization beyond simple locomotion therefore the request for a K3 prosthetic knee and advanced foot with K3 components 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 the K3 prosthetic knee and advanced foot with K3 components have not been met.Therefore, we decided that the Plan does not have to pre-approvethe K3 prosthetic knee and advanced foot with K3 components to be provided.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approvethe upper and lower partial denture.You asked the Plan to pre-approvethe upper and lower partial denture. You say that you have galvanism. You say that the medical justification was not verified to deny the service.The Plan denied your request. The Plan says that 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 coveragerules apply in this case. The Plan covers the upper and lower partial denture 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 upper and lower partial denture. Our reviewer says that the criteria for coverage has been met.Our reviewer says that flexible based partials are an accepted treatment incertain cases. Our physician reviewer foundthata flexible base fits the criteria for coverage since all other criteria for coverage are met.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules forcoverage of the upper and lower partial denture have been met.Therefore, we decided that the Plan has to pre-approvethe upper and lower partial denture.If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve implantable neurostimulator, pulse generator(L8679).You asked the Plan to pre-approve the implantable neurostimulator. You say that the records provided should support the necessity of the services in dispute.The Plan denied your request. The Plan says this service is considered not reasonable nor medically necessary and therefore is not covered.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 implantable neurostimulator. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is noted to have diffuse joint pain and sarcoidosis, for which anti-inflammatories and a rheumatology referral were ordered.  There is no documentation of the enrollee's response to the provided treatment or of a rheumatology evaluation.  There is no documentation of a plan to use the requested device or documentation of how the requested device is to fit in with ongoing treatment.  Therefore, the documentation does not support that the requested device is 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 implantable neurostimulator have not been met.Therefore, we decided that the Plan does not have to pre-approve implantable neurostimulator, pulse generator (L8679) to be provided.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay foran office visit (99214) provided on May 7, 2019.You asked the Plan to pay for the office visit. You say that you would like reconsideration as this surgery is long over. The Plan denied your request. The Plan says the services you received were not authorized by the Plan.Medicare rules say that plans may require enrollees to obtain authorization before receiving services. The contract with the Plan says that if you don't have a prior authorization before you get services from a specialist or certain other providers, you may have to pay for these services yourself.The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have topay for an office visit (99214) provided by the specialist on May 7, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 1 standard power operated vehicle and accessories.You asked the Plan to pre-approve a Group 1 standard power operated vehicle and accessories. You say that you need a scooter. The Plan denied your request. The Plan says there is no clinical evidence that your condition impairs your participation in MRADLs or a home evaluation.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. The file does not show that you have a mobility deficit that impairs your participation in MRADLs, or your condition cannot be improved by a walker, cane or manual wheelchair. This means that Medicare rules for coverage of a PMD have not been met.Therefore, we decided that the Plan does not have to pre-approve a Group 1 standard power operated vehicle and accessories.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea Mirena intrauterine device (IUD) for the enrollee.You asked the Plan to pre-approvethese services. You say that the enrollee needs the IUD for contraception.The Plan denied your request. The Plan says the services are not covered.The Plan must follow Medicare rules. The rules say that Medicare covers specific preventive services only.We looked at the file and Medicare rules. The services at issue are an IUD for contraceptive purposes. This is a preventive service that is not covered by Medicare.Therefore, we decided that the Plan does not have to pre-approvea Mirena intrauterine device (IUD) for the enrollee.Benefits for these servicesmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe medical services to be provided by an out of network provider.You asked the Plan to pre-approvethese services. You say that you have been seeing this provider for 10 years.The Plan denied your request. The Plan says the services are available from network providers.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-approvethe medical services to be provided.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an in-network exception for future services provided. You asked the Plan to pre-approve the in-network exception. You say that you are actively taking chemotherapy and would like to remain with the same providers who know your medical history. The in-network exception would be financially helpful. The Plan denied your request. The Plan says your provider did not send any of the requested medical documentation or plan of care to determine if these services could be covered in-network. Additionally, you did not obtain prior authorization for these services in the past, therefore, future services will not be covered as in-network.The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the in-network exception have not been met. You did not receive prior authorization and there is insufficient documentation to determine if these services meet criteria for an in-network exception. Therefore, we decided that the Plan does not have to pre-approve an in-network exception for future services.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approveTheraSkin grafts.You asked the Plan to pre-approve TheraSkin grafts. The Plan denied your request. The Plan says that this is not medically necessary.The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve TheraSkin grafts. Our reviewer says that the requested TheraSkin grafts are considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee is an 82-year-old female with anterior left lower leg and thigh wounds. The enrollee requires an efficient treatment with the real human skin allograft TheraSkin with growth factors, cytokines and collagens to jumpstart healing.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of TheraSkin grafts have been met.Therefore, we decided that the Plan has to pre-approveTheraSkin grafts.If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: 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 you prefer to use a portable oxygen concentrator so you can go other places and not haul around tanks.The Plan denied your request. The Plan says you were provided with a home oxygen concentrator and portable oxygen tanks for your oxygen needs within the home.The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. 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. The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home.Therefore, we decided that the Plan does not have to pre-approve a portable oxygen concentrator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvefoot orthotics (L3020).You asked the Plan to pre-approvefoot orthotics. You say that the requested items are necessary due to the pain you have been experiencing.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-approvefoot orthotics (L3020).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a So Clean CPAP cleaner for the enrollee.You asked the Plan to pre-approve this item. You say that the enrollee needs this to prevent infections in his lungs.The Plan denied your request. The Plan says that this is not covered by Medicare.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 SoClean CPAP cleaner for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve periodontal scaling and root planing(D4341) for the lower left and lower right quadrants, and gingival irrigation (D4921) for the lower left and lower right quadrants to be provided. You asked the Plan to pre-approve the gingival irrigation. You say that your dentist advised that you will lose your remaining front teeth if you do not have this procedure done.The Plan denied your request. The Plan says gingival irrigation is not listed as a covered service.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, gingival irrigation is not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approve periodontal scaling and root planing (D4341) for the lower left and lower right quadrants, and gingival irrigation (D4921) for the lower left and lower right quadrants to be provided.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Thumbster brace to be provided by an out of network provider. You asked the Plan to pre-approve the DME. You say that you are requesting review of denial of services.The Plan denied your request. The Plan says you do not have out-of-network benefits. 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 a Thumbster brace to be provided by an out of network provider.