Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the complete upper denture (D5110) to be provided by the doctor.
You asked the Plan to pre-approve the complete upper denture (D5110). You say that your denture broke in two parts. You say you are diabetic and not able to eat the right way. The Plan denied your request. The Plan says the service is covered, but the benefit is exhausted.
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, there is a benefit limit for the complete upper denture (D5110). The plan clearly states that only one denture (D5110, D5211 or D5213) is covered every 5 years. The records show the Plan paid for complete upper denture (D5110) on November 11, 2017, which exhausted the benefit. Therefore, we decided that the Plan does not have to pre-approve the complete upper denture (D5110) to be provided by the doctor.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional personal care service hours
You asked the Plan to pre-approve the additional hours. You say that the hours should not be reduced. The Plan denied your request. The Plan says there is no evidence provided warranting the additional hours per week for the needs of the member under her Medicaid benefit when utilizing the Medicaid state approved PCA Nursing Assessment tool.
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 additional hours. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found based on available records, you do not meet criteria for coverage of additional personal care hours. The records document the need for the 17 hours per week which have been approved. The additional hours would not be medically necessary and would be covering custodial services. 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 hours have not been met. Therefore, we decided that the Plan does not have to pre-approve additional personal care service hours
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion of interlaminar/interspinous process
stabilization/distraction 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 there is lack of evidence for this device.
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 services are not considered medically reasonable and necessary in this case. Our physician reviewer
found this device is considered experimental, and more research is needed.
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 insertion of interlaminar/interspinous process stabilization/distraction device for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair power seat elevation feature.
You asked the Plan to pre-approve the power seat elevation feature. You say that the enrollee needs the power elevation feature. The Plan denied your request. The Plan says a power seat elevation feature (E2300) is not covered by Medicare or the Plan.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the power seat elevation feature have not been met. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair power elevation feature.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued rental of a hospital grade breast pump. You asked the Plan to pre-approve continued rental of a hospital grade breast pump. You say that your baby is underweight and the hospital grade breast pump works better than standard pumps. The Plan denied your request. The Plan says neither you nor your baby meet the Plan's criteria for the continued rental. The Plan must follow Medicare rules. Medicare does not have published criteria for a hospital grade breast pump and therefore the Plan has established criteria. We looked at the file and Medicare rules. You do not meet the Plan's criteria and the baby's provider and dietician recommend transition to whole mild and solid foods. Based on this information, we decided that Medicare rules for coverage of continued rental of a hospital grade breast pump have not been met. Therefore, we decided that the Plan does not have to pre-approve continued rental of a hospital grade breast pump.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the ophthalmology services provided by out of network provider.
You asked the Plan to pre-approve the ophthalmology services. You say that you have seen an in-network ophthalmologist and would like another opinion from your provider. The Plan denied your request. The Plan says it has providers available in-network that can provide the services at issue.
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. The Plan did not pre-approve the services at issue. 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 the ophthalmology services provided by out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Transcutaneous Electrical Nerve Stimulator (TENS). You asked the Plan to pre-approve a TENS device. You say that you have all over full body pain in your joints and muscles. The Plan denied your request. The Plan says the presumed pain must be a type that is accepted as responding to TENS therapy. The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. The record shows the TENS device is being prescribed for TMJ pain. Based on this information, we decided that Medicare rules for coverage of a TENS device have not been met. Therefore, we decided that the Plan does not have to pre-approvea Transcutaneous Electrical Nerve Stimulator (TENS).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve chiropractic services. You asked the Plan to pre-approve these services. You say that you are requesting reconsideration of the plan's denial as the office is located 1 and 1/2 blocks from your home. The Plan denied your request. The Plan says the services can be rendered by an in-network provider at an acceptable distance. 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 practice 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 chiropractic services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approveinjections.You asked the Plan to pre-approveinjections. 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 medically necessary.The Plan follows Medicare rules. Medicare rules say that injections are only covered for certain indications.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 injections. Our reviewer says that the documentation does not supportthat the requested injections are medically reasonable or necessary. Our physician reviewer found you have chronic back pain. There is no documentation of conservative therapies such as physical medicine or chiropractic methods that have been recently tried. There is no documentation of facet loading tests or range of motion limitations of the lumbar spine. Therefore, you do not meet criteria for the requested injections.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of injections have not been met.Therefore, we decided that the Plan does not have to pre-approveinjections.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 3 power wheelchair for the enrollee.You asked the Plan to pre-approve these services. You say that the enrollee needs this following surgery.The Plan denied your request. The Plan says that use of a cane or walker is supported.The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for enrollees who have a mobility limitation that is due to:1. A neurological condition;2. Myopathy; or3. Congenital skeletal deformity.The file does not show that A. Lev has a mobility limitation that is due to a neurological condition, myopathy or congenital skeletal deformity.Therefore, we decided that the Plan does not have to pre-approve a Group 3 power wheelchair for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea shower chair.You asked the Plan to pre-approvea shower chair. You say that the enrollee suffers from dizziness and nausea. You say that the enrollee lives alone and would benefit from having the shower chair as it would prevent any injuries that could occur from a fall in the shower.The Plan denied your request. The Plan says this item 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 Plan does not have to pre-approvea shower chair.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approveamagnetic resonance imaging (MRI) of the shoulder (73221).You asked the Plan to pre-approvean MRI of the shoulder. You say that the requested service is medically necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.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 an MRI of the shoulder. Our reviewer says that the service is not medically necessary. Our physician reviewer found the documentation does not reveal the outcome ofcortisone injections for the right shoulder. The documentation does not reveal duration of right shoulder pain, evidence of physical therapy for the right shoulder, quantification of shoulder pain, or red flag findings. Without evidence of outcome of conservative measures first the request for a right shoulder MRI 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 an MRI of the shoulder have not been met.Therefore, we decided that the Plan does not have to pre-approvea magnetic resonance imaging (MRI) of the shoulder (73221).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a total electric hospital bed.
You asked the Plan to pre-approve a total electric hospital bed. You say that you are handicapped and have
cerebral palsy which makes sleeping in a standard hospital bed very uncomfortable. The Plan denied your
request. The Plan says that total electric hospital beds are not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital
bed.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Feldenkrais method of physical therapy.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the Feldenkrais method of physical therapy is not considered medically necessary or a standard of care.
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 services. Our reviewer says that the requested therapy is not considered medically reasonable and necessary in this case. Our physician reviewer found the method of physical therapy "Feldenkrais" is not a standard practice for treatment of chronic back pain and appears to be no more beneficial than traditional Physical therapy with both land and water based exercises. The enrollee should be referred to Aqua therapy with PT instead. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve the Feldenkrais method of physical therapy.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sclerotherapy treatment for varicose veins.
You asked the Plan to pre-approve the requested sclerotherapy. You say that the enrollee requires this treatment. The Plan denied your request. The Plan says there has not been a sufficient trial of conservative management.
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 requested sclerotherapy. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the patient is an 82-year-old woman with numerous comorbidities including hypertension, hyperlipidemia, chronic kidney disease, and degenerative joint disease involving multiple joints. There is a description of spider and reticular veins but it is not clear that her activity limitation is not due to her multiple joint arthritis. She has an alarming family history with respect to vascular disease. Her physical exam describes normal pedal pulses and no edema. She is described as being noncompliant with her medications including those that would control fluid management. She does not have enlargement of the veins slated for treatment. There does not appear to have been any effort to treat this conservatively particularly an 82-year-old woman with numerous comorbidities. This treatment is not medically reasonable and necessary 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 requested sclerotherapy have not been met. Therefore, we decided that the Plan does not have to pre-approve sclerotherapy treatment for varicose veins.
Appeal type: Imaging
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 Computed Tomography (CT) of the orbit, sella, or posterior fossa or outer, middle, or inner ear (70480). You say that the requested service is medically necessary. The Plan denied your request. The Plan says there are in-network providers available that can provide the service at issue.
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a cochlear implant.You asked the Plan to pre-approve these services. You say that you have hearing issues.The Plan denied your request. The Plan says the services are not medically necessary.The Plan must follow Medicare rules.Medicare rules say that a cochlear implant is covered when specific criteria are met.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 services are not medically necessary. Our physician reviewer found the records show that you have a diagnosis of unspecified hearing loss in both ears. The records do not show that you have the ability to use 
auditory clues and willingness to undergo an extended rehabilitation program. You do not have a middle ear infection or cochlear structure that is suited to implantation. The documentation does not support that the cochlear implant is reasonable andmedically necessary 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 these services have not been met.Therefore, we decided that the Plan does not have to pre-approve a cochlear implant.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a mitral valve repair surgery to be provided by the doctor at a tertiary facility.
You asked the Plan to pre-approve the surgical services. You say that it is medically necessary for you to receive minimally invasive mitral valve surgery (MIMVS) at a tertiary facility. You say that this doctors facility do not perform robotic MIMVS. You also say that the doctor and his team are very experienced with this kind of surgery. The Plan denied your request. The Plan says a tertiary level of care is not necessary. The Plan says the requested provider is not a network provider. The Plan also says you have been approved for a consult with the doctor for an evaluation of surgical options and to determine if the doctor would perform the surgery.
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 surgical services. Our reviewer says that the requested service is not medically necessary. Our physician reviewer found the enrollee has mitral regurgitation being considered for surgical repair that can be accomplished invasively through a median sternotomy or minimally invasively using smaller parasternal incisions. These two approaches have similar outcomes with respect to overall mortality, stroke, myocardial infarction and reduction in mitral regurgitation. Since these outcomes are observed to be clinically similar and since there are no randomized trials comparing these two approaches, the services can be provided within the Plan's network.
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 surgical services have not been met. Therefore, we decided that the Plan does not have to pre-approve a mitral valve repair surgery to be provided by the doctor at a tertiary facility.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve personal care assistant (PCA) services, 18.5 hours per week.
You asked the Plan to pre-approve the PCA services. You say that you feel that this is needed. The Plan denied your request. The Plan says you have had PCA services approved under your Medicaid benefit. This cannot be covered by the Medicare portion of your plan.
The Plan must follow Medicare rules. Medicare rules say that custodial care, such as PCA services, is not covered. Therefore, we decided that the Plan does not have to pre-approve personal care assistant (PCA) services, 18.5 hours per week under your Medicare benefit.