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

We decided that the Plan does not have to pre-approve contact lenses (V2530).

You asked the Plan to pre-approve contact lenses. You say that the contact lenses are medically necessary and important for you to maintain your independence. The Plan denied your request. The Plan says the contacts are not covered under your benefits.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers contact lenses when they are prescribed following cataract surgery. 

We looked at the file and the Plan's rules. You are requesting coverage of contact lenses for vision correction unrelated to cataract surgery. Based on this information, we decided that the Plan's rules for coverage of contact lenses have not been met. Therefore, we decided that the Plan does not have to pre-approve contact lenses (V2530).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (K0553, K0554).

You asked the Plan to pre-approve the continuous glucose monitor. You say that the continuous glucose monitor is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. 

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not inject insulin at least three times per day. Based on this information, we decided that Medicare rules for coverage of the continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (K0553, K0554).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair replacement.
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 records do not show that the current wheelchair is broken.
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 wheelchair is not medically reasonable or necessary. Our physician reviewer found the documentation does not indicate that the current wheelchair is broken in a way that is not possible to repair. There is no evidence of a change in function.
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 replacement.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6454.
You asked the Plan to pre-approve the compression stockings. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6454 are noncovered because they do not meet the statutory definition of a surgical dressing. Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6454.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitor (CGM).
You asked the Plan to pre-approve a Dexcom G6. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested services.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. We looked at the file and Medicare rules. While the enrollee does meet CGM criteria, the documentation does not support that the Plan's preferred product of a Freestyle Libre 2 would not be effective for the enrollee. The do Based on this information, we decided that Medicare rules for coverage of a Dexcom G6 have not been met. Therefore, we decided that the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitor (CGM).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a maxillary partial denture (D5213).
You asked the Plan to pay for the maxillary partial denture. You say that you would like this service to be approved for coverage. The Plan denied your request. The Plan says this service exceeds the maximum count allowed per period.
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, maxillary partial denture (D5213) is limited to one procedure every five plan years. The record shows that you received a maxillary partial denture (D5213) on February 28, 2020 and your maxillary partial denture (D5213) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for a maxillary partial denture (D5213).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an implant supported removable upper denture (D6110) and the replacement of a replaceable part of semi-precision or precision attachment (D6091 x 4).
You asked the Plan to pre-approve the dental services. You say that you have been told that the denture is not covered. You say that this service is merely a removable denture that is placed over implants. You say that you are not asking for any type of implant service to be covered. You also say that when you signed up for this plan, you were told that dentures were covered. The Plan denied your request. The Plan says implant supported removable upper denture is not listed as a covered service. The Plan says that replacement of a replaceable part of semi-precision or precision attachment is not listed as a covered service either.
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 an implant supported removable upper denture (D6110) and the replacement of a replaceable part of semi-precision or precision attachment (D6091 x 4).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the services are 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. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily
skilled services are not necessary. Our physician reviewer found continued care in the acute inpatient
rehabilitation facility is appropriate until the enrollee is stable to transfer to a lower level of care such as a longterm
care facility or home with home health 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 SNF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute 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 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. You were admitted for vessel coronary bypass grafting and left atrial appendage surgery. Medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports 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 IRF admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Repatha.
You asked the Plan to pre-approve Repatha. You say that the medication is necessary. The Plan denied your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage.
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 Repatha.
Benefits for Repatha 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a comprehensive metabolic panel (80053), lipid panel
(80061), thyroxine (84439), thyroid stimulating hormone (84443), and blood count (85025) provided on
October 20, 2020.
You asked the Plan to pay for the laboratory services. You say that you would like reconsideration based on the
records submitted. The Plan denied your request. The Plan says these services are not authorized because
predictive screening testing is not a Medicare benefit.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed above, are not covered.
The test at issue in this appeal, the laboratory services, was requested solely for screening purposes. Medicare
does not cover this test solely for screening purposes.
Therefore, we decided that the Plan does not have to pay for a comprehensive metabolic panel (80053), lipid
panel (80061), thyroxine (84439), thyroid stimulating hormone (84443), and blood count (85025) provided on
October 20, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a left knee orthosis (L1833) and a suspension sleeve (L2397).

You asked the Plan to pay for a knee orthosis and a suspension sleeve. You say that the requested items are a medical necessity for the enrollee. The Plan denied your request. The Plan says there is no documentation of a video or telephonic visit by the ordering physician to warrant the codes billed.

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 pay for a knee orthosis and a suspension sleeve. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee has osteoarthritis. There is no documentation of a recent injury or surgical procedure upon the knee. The medical records provide do not support an objective assessment of knee instability. The record documents a subjective description of the instability.

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 knee orthosis and a suspension sleeve have not been met. Therefore, we decided that the Plan does not have to pay for a left knee orthosis (L1833) and a suspension sleeve (L2397).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services provided October 4, 2020, to October 12,
2020, by a provider located outside the United States.

You asked the Plan to pay for surgical services. You say that you would like the Plan to reconsider their denial
for medical necessity. The Plan denied your request. The Plan says coverage for non-emergent services
provided out-of-country are not covered.

The Plan must follow Medicare rules. Medicare rules say that most services provided outside the United States
are not covered.

We looked at the file and Medicare rules. In this case, the services were provided outside of the country. There
is no exception that would allow Medicare to cover this surgery. In addition, the Plan's contract makes it clear
that pre-scheduled/elective procedures performed in another country are not covered. Based on this
information, we decided that Medicare rules for coverage of surgical services have not been met. Therefore, we
decided that the Plan does not have to pay for surgical services provided October 4, 2020, to October 12, 2020,
by a provider located outside the United States.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on January 25, 2021.
You asked the Plan to pay for the comprehensive exam. You say that you saw one dentist who presented you with a very costly treatment plan. You chose to pick a new dentist. You feel this second dentist provided much better care and do not understand why some of the services billed were denied. The Plan denied your request. The Plan says you received a comprehensive oral evaluation on January 21, 2021. This exam was covered by the Plan. Comprehensive evaluations may only be covered once every three plan years. This service was denied correctly.
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 comprehensive evaluation is requested in a frequency not covered under this benefit. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on January 25, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of a Superion interspinous stabilization device (22869).
You asked the Plan to pre-approve this service. You say that this service is medically necessary for the enrollee. The Plan denied your request. The Plan says this service is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve this service. Our reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our physician reviewer found that the spacer device remains 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 this service have not been met. Therefore, we decided that the Plan does not have to pre-approve the insertion of a Superion interspinous stabilization device (22869).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a spinal fusion procedure (63047, 22558, 22612, 22840).

You asked the Plan to pre-approve the spinal fusion procedure. You say that the spinal surgery is medically necessary. The Plan denied your request. The Plan says coverage criteria 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 the spinal fusion procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there are no recent imaging studies showing severe compression of the nerve roots. There is no evidence of spinal instability on imaging studies. 

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 spinal fusion procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve a spinal fusion procedure (63047, 22558, 22612, 22840).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of a Superion interspinous stabilization device (22869, 22870).
You asked the Plan to pre-approve this service. You say that this service is medically necessary for the enrollee. The Plan denied your request. The Plan says this service is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve this service. Our reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our physician reviewer found that the Superion spacer 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 this service have not been met. Therefore, we decided that the Plan does not have to pre-approve the insertion of a Superion interspinous stabilization device (22869, 22870).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Volara system vest (E1399).

You asked the Plan to pre-approve the Volara system vest. You say that the device is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.

The Plan must follow Medicare rules. Medicare rules say that a diagnosis of Chronic Obstructive Pulmonary Disorder (COPD) alone in the absence of Bronchiectasis does not meet coverage criteria. 

We looked at the file and Medicare rules. The provided records show there is no diagnosis of Cystic Fibrosis, Bronchiectasis, or neuromuscular disease. Based on this information, we decided that Medicare rules for coverage of the Volara system vest have not been met. Therefore, we decided that the Plan does not have to pre-approve a Volara system vest (E1399).
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 for the enrollee.
You asked the Plan to pre-approve IRF care. You say that the member needs 24-hour nursing care, physician oversight, intense inpatient physical therapy. The Plan denied your request. The Plan says that the enrollee can safely receive the services needed, in other settings.
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. The enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to be able to tolerate fifteen hours per week of rehabilitative services or to require regular physician evaluation. The enrollee's care needs can be met at a lower level of care. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF care. 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 for the enrollee.