Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve an epidural steroid injection.

You asked the Plan to pre-approve the injection. You say that the pain is interfering with activities of daily living. The Plan denied your request. The Plan says that the MRI does not show significant imaging abnormalities, such as central spinal stenosis, central disc herniation, or severe degenerative disease.

The Plan must follow Medicare rules. Medicare rules say that services are covered 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 injection. Our reviewer says that the requested injection is considered medically reasonable and necessary in this case. Our physician reviewer found you have documented foraminal stenosis at L4-L5. You have tried physical therapy in the past. There is an indication for the requested injection.

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 injection have been met. Therefore, we decided that the Plan has to pre-approve an epidural steroid injection.

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: 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 require these services in order to fully recover
and be fully mobile again. The Plan denied your request. The Plan says that you can safely receive the services
you need 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
complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay
with an interdisciplinary approach to rehabilitation care. You were admitted for cervical spine surgery after a
ground level fall. Your 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. Our
physician reviewer found that your 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.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete upper denture (D5110), and a complete lower denture (D5120).

You asked the Plan to pre-approve a complete upper denture, and a complete lower denture. You say that you lost your dentures and need them replaced. The Plan denied your request. The Plan says the services are a covered benefit, but you have exceeded the frequency limit of one every 5 years.

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. 

We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a complete upper denture, and a complete lower denture have not been met. Specifically, the record shows that you had exceeded the frequency limit prior to this service on October 1, 2020. Therefore, we decided that the Plan does not have to pre-approve a complete upper denture (D5110), and a complete lower denture (D5120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve removal of torus palatinus (D7472) and removal of
torus mandibularis (D7473).
You asked the Plan to pre-approve the dental services. You say that you have been turned down because your
mouth is not like anybody else's. You also say that this is discrimination. The Plan denied your request. The
Plan says removal of torus palatinus is not listed as a covered service. The Plan says that removal of torus
mandibularis 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
removal of torus palatinus (D7472) and removal of torus mandibularis (D7473).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex Superion interspinous distraction device
(22869, 22870).

You asked the Plan to pre-approve the Vertiflex device. You say that you highly recommend this minimally
invasive procedure when conservative treatment has failed and as a safer alternative to a laminectomy or spinal
fusion procedure. The Plan denied your request. The Plan says the requested procedure is considered
experimental and investigational intervention for spinal stenosis and back pain.

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 the Vertiflex device have not been met. Therefore, we decided that the Plan does not have to preapprove
the Vertiflex Superion interspinous distraction device (22869, 22870).
Appeal type: Practitioner Services
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 a review of the current medical literature indicates that this service is considered
experimental and investigational.
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.
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bioimpedance spectroscopy for the enrollee.

You asked the Plan to pre-approve the procedure. You say that this is medically necessary, as the enrollee could not tolerate a breast MRI, due to extreme claustrophobia and difficulty with sedation. The Plan denied your request. The Plan says this 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 the procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation indicates that the enrollee has a history of grade 1 diastolic dysfunction, EF of 70%, and left ventricular hypertrophy. She had a heart catheterization. She has multiple medication allergies/sensitivities and reacts poorly to anesthesia. She does not feel she could tolerate a breast MRI because of extreme claustrophobia and difficulty with sedation. The review indicates that there is no specific clinical rationale for the requested bioimpedance spectroscopy. It has already been determined that the enrollee would not undergo sentinel lymph node biopsy. The requested service is experimental/investigational. NCCN guideline does not mention bioimpedance in the treatment guidelines.

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 bioimpedance spectroscopy for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve crowns (D2752) for teeth # 5, 13, and 22.
You asked the Plan to pre-approve crowns for teeth # 5, 13, and 22. You say that the crowns are medically
necessary. The Plan denied your request. The Plan says 2 crowns are covered per calendar year, per patient.
The Plan also says that the frequency limit 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 listed as covered, the
frequency limit has been reached. The record shows that the Plan approved crowns for teeth # 3, 12, and 31.
Therefore, we decided that the Plan does not have to pre-approve crowns (D2752) for teeth # 5, 13, and 22.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Dexcom G6 therapeutic continuous glucose monitor.

You asked the Plan to pre-approve a Dexcom G6. You say that this device is medically necessary for the enrollee. The Plan denied your request. The Plan says the patient has not had a trial of the preferred product and there is no evidence the patient cannot use the preferred product.

The Plan follows Medicare rules. Medicare rules say that a Plan is allowed to specify a preferred brand for devices when it adheres to the criteria listed 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 a Dexcom G6. Our reviewer says that the request for the Dexcom G6 therapeutic continuous glucose monitor is not medically necessary and reasonable. Our physician reviewer found that the Plan's preferred brand therapeutic continuous glucose monitor is Freestyle Libre. There is no evidence that the enrollee needs the requested Dexcom G6 over Freestyle Libre and it appears that the Plan's preferred brand would be sufficient for managing the enrollee's medical condition.

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 Dexcom G6 have not been met. Therefore, we decided that the Plan does not have to pre-approve a Dexcom G6 therapeutic continuous glucose monitor.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve spinous process distraction device procedure.
You asked the Plan to pre-approve spinous process distraction device procedure. 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 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 spinous process distraction device procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has low back pain. The distraction device is experimental. More research is needed to show safety and efficacy. Therefore, the enrollee does not meet criteria for the requested 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 spinous process distraction device procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve spinous process distraction device procedure.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve medical management to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve medical management. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services can be provided by a network provider.
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 medical management 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 referral to an out-of-network provider.
You asked the Plan to pre-approve these services. You say that the Plan does not offer treatment for your condition. 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 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. The Plan confirmed that the network providers are able to treat your diagnosis of peripheral neuropathy. 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 to an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an upright walker.
You asked the Plan to pre-approve upright walker. You say that the enrollee's current walker is not the correct
size, so the enrollee is always bending over while ambulating which causes neck and back pain. The Plan
denied your request. The Plan says the denial of authorization for this item is correct, because this walker does
not meet the enrollee's needs.
The Plan follows Medicare rules. Medicare rules state that a walker may be covered if certain specific clinical
indications 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 upright walker. Our reviewer says that
the enrollee does not meet the Medicare criteria for the requested walker.
Our physician reviewer found the documentation indicates that the enrollee has a mobility limitation but does not clearly indicate that it impairs mobility-related activities of daily living (MRADLs). The documentation does not reveal that the enrollee requires an upright walker and that his functional deficit cannot be sufficiently resolved with use of a standard walker. The requested walker exceeds the enrollee's medical needs. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of upright walker have not been met. Therefore, we decided that the Plan does not have to pre-approve an upright walker.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve precision attachments (D5862) and surgical placement of an implant body (D6010) for teeth # 22 and 27.
You asked the Plan to pre-approve the dental services. You say that you understand that these services are not covered. You say that it is embarrassing to be in conversation with someone and your dentures fall out of your mouth. You also say that you cannot eat properly. The Plan denied your request. The Plan says precision attachments are not listed as covered services. The Plan says surgical placement of implant bodies are not listed as covered services 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 precision attachments (D5862) and surgical placement of an implant body (D6010) for teeth # 22 and 27.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Alzheimer Disease Evaluation (ADEVL) diagnostic testing (83520).
You asked the Plan to pre-approve ADEVL diagnostic testing. You say that this is necessary due to the enrollee's cognitive issues. The Plan denied your request. The Plan says this is experimental.
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 ADEVL diagnostic testing. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this testing has not been shown to have sufficient specificity to lead to meaningful changes in management or outcomes. This is considered experimental and investigational. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of ADEVL diagnostic testing have not been met. Therefore, we decided that the Plan does not have to pre-approve Alzheimer Disease Evaluation (ADEVL) diagnostic testing (83520).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 6 additional PT visits.
You asked the Plan to pre-approve the additional PT visits. You say that the enrollee will be unable to get in and out of his home safely without the additional PT visits. The Plan denied your request. The Plan says the enrollee does not meet criteria for additional home health services.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 PT visits. Our reviewer says that the requested home health services are not medically necessary. Our physician reviewer found the documentation does not support that the enrollee requires additional skilled rehab services to provide treatment that is medically necessary. The enrollee does not require additional skilled rehab services to effectively provide treatment, care, and/or services in order to improve the enrollee's condition, perform a maintenance program to maintain the enrollee's condition and/or prevent deterioration. Our reviewer found that the enrollee has been medically stable without any recent exacerbations of chronic medical problems or hospitalizations. Our physician reviewer also found that the enrollee improved with in-home PT services and should be independent with a home exercise program. 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 PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 6 additional PT visits.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an allograft, autograft, arthrodesis, and insertion of biomechanical device.

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 the services are 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has lumbar spinal stenosis and is planned for lumbar laminectomy. The requested hardware and graft items are not needed for the enrollee's condition. The services are not reasonable or medically necessary. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve an allograft, autograft, arthrodesis, and insertion of biomechanical device.