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

We decided that the Plan does not have to pre-approve a continuous glucose monitor.
You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your request. The Plan says there is no documentation of insulin use. 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 monitor. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found you are not on insulin, and do not meet the criteria. There is no information on what the blood glucose information is being used for. 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 monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an auricular nerve stimulator for the enrollee.
You asked the Plan to pre-approve the stimulator. You say that this is medically necessary. The Plan denied your request. The Plan says this is considered investigational and experimental.
The Plan must follow Medicare rules. Medicare rules say that acupuncture for stimulation of auricular points is not a covered Medicare benefit. 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 stimulator. Our reviewer says that our physician reviewer found 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 stimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve an auricular nerve stimulator for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve localized delivery of antimicrobial agents via controlled release vehicle into diseased crevicular tissue (D4381) for tooth # 21.
You asked the Plan to pre-approve the dental service. You say that this service is necessary. The Plan denied your request. The Plan says localized delivery of antimicrobial agents 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, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve localized delivery of antimicrobial agents via controlled release vehicle into diseased crevicular tissue (D4381) for tooth # 21.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Dupixent.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says self-administered drugs are not covered.
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 Dupixent.
Benefits for these services may 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill (SSBCI).
You asked the Plan to pre-approve special supplemental benefits for the chronically ill. You say that you have hyperlipidemia, osteoporosis, esophageal gastro reflux, arthritis, cannot walk well, your arm does not react as it did before, you hurt your hand, and had bowel surgery. The Plan denied your request. The Plan says you do not have any of the eligible medical conditions, do not have a high risk of hospitalization or other adverse health outcomes, and do not require intensive care coordination, so you do not qualify for special supplemental benefits for the chronically ill.
The Plan must follow Medicare rules. Medicare rules say that plans may implement special supplemental benefits for the chronically ill. The Plan contract says that the Plan offers special supplemental benefits for the chronically ill for enrollees who have certain eligible conditions, have a high risk of hospitalization or other adverse health outcomes, and require intensive care coordination. We looked at the file, Medicare rules, and the Plan's rules. You do not have an eligible condition for the Plan's special supplemental benefits for the chronically ill. Based on this information, we decided that Medicare rules for coverage of special supplemental benefits for the chronically ill have not been met. Therefore, we decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill (SSBCI).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair with tilt/recline.
You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied your request. The Plan says the reasonable useful lifetime of this chair is to be no less than five years.
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 wheelchair. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found based on the medical records provided there is no documentation that there is any specific medical need to replace the wheelchair when one was received in May 2020. The records do not document that the present power wheelchair has reached its reasonable useful lifetime or has been lost or irreparably damaged. 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 wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair with tilt/recline.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that you are not getting the care you need at the current facility and wish to change to the IRF. The Plan denied your request. The Plan says the denial of IRF care is correct.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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 the complexity of your nursing, medical, and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the records support a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that you will be able to fully participate in - and benefit from - the intensive rehabilitation therapy program provided in an IRF. 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-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex 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 experimental and investigational procedures are 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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the device is experimental. More research is needed to show safety and efficacy of the device. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two semi-precision attachment abutments (D6052 x2), implant removal (D6100), and mandibular implant/abutment supported removable denture for partially edentulous arch (D6113).
You asked the Plan to pre-approve the semi-precision attachment abutments, implant removal, and mandibular implant/abutment supported removable denture. You say that these services are medically necessary. You also say that you need these services but cannot afford to pay for them. 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-approve two semi-precision attachment abutments (D6052 x2), implant removal (D6100), and mandibular implant/abutment supported removable denture for partially edentulous arch (D6113).
Appeal type: Supplemental Benefit
Decision: Unfavorable

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

We decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150) and several tooth extractions (D7210) to be provided by an oral surgeon.
You asked the Plan to pre-approve dental services provided by an oral surgeon. You say that these services are medically necessary due to extreme decay and pain. The Plan denied your request. The Plan says these services are not covered by Medicare and are only partially eligible for coverage under the Plan's supplemental dental benefit when they are provided by a participating general dentist. Services provided by an oral surgeon are not 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, services provided by an oral surgeon are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150) and several tooth extractions (D7210) to be provided by an oral surgeon.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation, nerves innervating the sacroiliac joint (64625).
You asked the Plan to pre-approve radiofrequency ablation. You say that you are appealing authorization request with valid clinical documents. Kindly reconsider. The Plan denied your request. The Plan says this service is considered experimental or investigational. Research has not proven this service to be helpful.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The rules also say that experimental and investigational devices are not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of radiofrequency ablation have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation, nerves innervating the sacroiliac joint (64625).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa.
You asked the Plan to pre-approve Euflexxa. You say that the enrollee has failed a steroid injection. The Plan denied your request. The Plan says step therapy requirements 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 Euflexxa. Our reviewer says that the criteria for coverage of Euflexxa have not been met. Our physician reviewer found the Plan requires a trial of Orthovisc and Monovisc before they will approve the requested drug. In this case, the patient has not tried and failed the required drugs. There is no documentation provided indicating that the plan's required drugs would likely be less effective or 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 Euflexxa have not been met. Therefore, we decided that the Plan does not have to pre-approve Euflexxa.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Intracept procedure (intraosseous basivertebral nerve ablation, L3-L4) for the enrollee.
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied your request. The Plan says there is insufficient evidence of the efficacy of this procedure.
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 procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is limited published peer-reviewed literature that shows the request to be an effective and/or safe treatment for the noted pathology. In addition, there are multiple plausible sites of spinal pain generation (including but not limited to the facets and stenosis) at multiple lumbar levels. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines. Therefore, the request for Intracept procedure at L3 and L4 is 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 the procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the Intracept procedure (intraosseous basivertebral nerve ablation, L3-L4) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve durable medical equipment to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve durable medical equipment. You say that you would like approval for this durable medical equipment. The Plan denied your request. The Plan says there are in-network providers available for these services.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the 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 durable medical equipment to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a stretching machine.
You asked the Plan to pre-approve the machine. You say that this is a much-needed part of therapy. The Plan denied your request. The Plan says this is only covered after knee surgery.
The Plan must follow Medicare rules. The rules say that CPM devices are covered only for patients who have received total knee replacement surgery. You have not had total knee replacement surgery. Therefore, we decided that the Plan does not have to pre-approve a stretching machine.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a consult and extraction to be provided by an oral surgeon.
You asked the Plan to pre-approve the consult and extraction. You say that you were referred to an oral surgeon to receive these services. The Plan denied your request. The Plan says your contract with the Plan only provides coverage for dental services when they are performed by a participating general dentist. The Plan also says that dental services performed by an oral surgeon are not 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 items or services are not covered when they are received by anyone other than a participating general dentist. Therefore, we decided that the Plan does not have to pre-approve a consult and extraction to be provided by an oral surgeon.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a walk-in tub.
You asked the Plan to pre-approve the tub. You say that you have discomfort in your pain, making it more difficult to shower. The Plan denied your request. The Plan says this item does not serve a medical purpose.
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 walk-in tub.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve MRI of the brain for the enrollee.
You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your request. The Plan says that the treating doctor did not submit any history, diagnosis, or physical exam.
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 requested MRI is medically reasonable and necessary. Our physician reviewer found in this case, the medical records demonstrate that the enrollee underwent resection and gamma knife treatment of a recurrence. The most recent MRI demonstrated a recurrence. The requested scan is medically reasonable and necessary as defined by the coverage rules. 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 been met. Therefore, we decided that the Plan has to pre-approve MRI of the brain for the enrollee.
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.