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

We decided that the Plan does not have to pre-approve a continuous passive motion exercise device for use other than knee (E0936).

You asked the Plan to pre-approve a continuous passive motion exercise device. You say that you are having rotator cuff surgery and will need this device. The Plan denied your request. The Plan says this is not a covered service when used for something other than total knee replacement surgery.

The Plan must follow Medicare rules. Medicare rules say that a continuous passive motion device is only covered after a total knee replacement surgery. 

We looked at the file and Medicare rules. In this case, you are requesting a continuous passive motion device after shoulder surgery, not a total knee replacement. Based on this information, we decided that Medicare rules for coverage of a continuous passive motion exercise device have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous passive motion exercise device for use other than knee (E0936).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion of an interspinous spacer device (Vertiflex).

You asked the Plan to pre-approve Vertiflex. You say that you are appealing with medical records. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because Vertiflex is experimental/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 Vertiflex. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental. More research is needed to show its 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 Vertiflex have not been met. Therefore, we decided that the Plan does not have to pre-approve insertion of an interspinous spacer device (Vertiflex).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 1 power operated vehicle (K0800).
You asked the Plan to pre-approve a group 1 power operated vehicle. You say that this item is necessary. The Plan denied your request. The Plan says the rules for a power operating vehicle have not been met.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. The file shows that your condition can be improved by a walker, cane or manual wheelchair. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a group 1 power operated vehicle (K0800).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Dupixent 300/2ml injectable medication.
You asked the Plan to pre-approve this medication. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says this medication is not a covered benefit under the enrollee's contractual policy.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drug requested here is not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve the Dupixent 300/2ml injectable medication.
Benefits for this medication 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 1st Bilateral L3-5 Medial Branch Block (Codes: 64493/ 64494).
You asked the Plan to pre-approve the medial branch block. You say that MBB will not be used to treat enrollee's radicular pain. You will be treating enrollee's axial low back pain with MBB's. You have attached imaging and notes. The Plan denied your request. The Plan says the documentation received does not support the need for this service.
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 medial branch block. 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 not had a recent physical exam. Therefore, the request does not meet the LCD criteria and is deemed 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 medial branch block have not been met. Therefore, we decided that the Plan does not have to pre-approve 1st Bilateral L3-5 Medial Branch Block (Codes: 64493/ 64494).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the services of a home health/hospice aide (G0156).
You asked the Plan to pre-approve the home health/hospice aide services. You say that you need these services.
The Plan denied your request. The Plan says you are not currently homebound nor receiving skilled services at
your home. The Plan also say that this does not meet the criteria for Home Health Services and is not covered.
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically
necessary for the enrollee to receive skilled nursing or therapy.
We looked at the file and Medicare rules. Aside from bathing services, you are not receiving any other skilled
home health care services that are listed. Based on this information, we decided that Medicare rules for
coverage of the home health/hospice aide services have not been met. Therefore, we decided that the Plan does
not have to pre-approve the services of a home health/hospice aide (G0156).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the therapeutic continuous glucose monitor and supplies (K0553, K0554).
You asked the Plan to pre-approve the therapeutic continuous glucose monitor and supplies. You say that this item is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the criteria for the continuous glucose monitor have 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 use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of the therapeutic continuous glucose monitor and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve the therapeutic continuous glucose monitor and supplies (K0553, K0554).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dermatology services to be provided by an out of network provider.

You asked the Plan to pre-approve dermatology services with an out of network provider. You say that you need a dermatologist to examine your medical condition. The Plan denied your request. The Plan says the service is medically necessary but there are in-network providers who can evaluate and treat you.

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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services from an out of network provider. Therefore, we decided that the Plan does not have to pre-approve dermatology services to be provided by an out of network provider.

Please note, The Plan has approved an in-network dermatologist for your services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill.
You asked the Plan to pre-approve special supplemental benefits for the chronically ill. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says you do not meet criteria for the requested services.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation. While the Plan does have a supplemental (extra) benefit that covers the requested special benefits under certain indications. Review of the file shows that you are requesting special supplemental benefits for the chronically ill. While the documentation does support that you have anemia, the documentation does not support that you require intense care coordination, are high risk for hospitalizations or high risk for adverse health outcomes. Although these may be appropriate, the Plan does not provide coverage for them. Therefore, we decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve eyeglasses from a non-participating provider.

You asked the Plan to pre-approve eyeglasses from a non-participating provider. You say that you would like to get your glasses from an online vendor because they are cheaper, and you cannot afford the ones the Plan offers. The Plan denied your request. The Plan says eyeglasses provided from non-participating providers cannot be covered.

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 one pair of eyeglasses every 2 calendar years from participating network providers. 

We looked at the file and the Plan's rules. The Plan does not offer coverage of eyeglasses outside the Plan's network. Therefore, we decided that the Plan does not have to pre-approve eyeglasses from a non-participating provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve colonoscopy services to be provided by an out of
network (OON) provider.

You asked the Plan to pre-approve colonoscopy services. You say that you would like this reprocessed for
approval. 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
colonoscopy services 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 the consultation with an out-of-network neurologist.
You asked the Plan to pre-approve the consultation. You say that there is a non-determination of what is wrong
based on one opinion. You say that a second opinion is needed from the specialty hospital. The Plan denied
your request. The Plan says in-network neurologists are available.
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
the consultation with an out-of-network neurologist.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6530.
You asked the Plan to pre-approve the compression stockings. You say that this is medically necessary. The Plan denied your request. The Plan says this is not covered.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 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 A6530.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental extractions to be provided by an oral surgeon.
You asked the Plan to pre-approve dental extractions to be provided by an oral surgeon. 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 a covered benefit.
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 dental extractions to be provided by an oral surgeon.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Cyclobenzaprine 10mg tablets.
You asked the Plan to pre-approve Cyclobenzaprine. You say that Cyclobenzaprine is medically necessary. The Plan denied your request. The Plan says this drug is not eligible for coverage under the Part B medical benefit.
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 Cyclobenzaprine 10mg tablets.
Benefits for Cyclobenzaprine 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve transurethral destruction of prostate tissue services.
You asked the Plan to pre-approve transurethral destruction of prostate tissue services. 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 the transurethral destruction of prostate tissue
service is only covered for certain indications.
We looked at the file and Medicare rules. The documentation does not support documentation of symptoms
despite maximal medical management as well as a prostate specific antigen (PSA) score. Based on this
information, we decided that Medicare rules for coverage of transurethral destruction of prostate tissue services
have not been met. Therefore, we decided that the Plan does not have to pre-approve transurethral destruction
of prostate tissue services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.
You asked the Plan to pre-approve a shower chair. You say that you need this item for safety reasons. The Plan
denied your request. The Plan says these items are hygiene equipment and are not covered.
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-approve a shower chair.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve re-titration for bilevel positive airway pressure (BIPAP).

You asked the Plan to pre-approve re-titration for BIPAP. 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 re-titration for BIPAP is 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 re-titration for BIPAP. Our reviewer says that the documentation does not support that the requested services are medically reasonable or necessary. Our physician reviewer found the enrollee has obstructive sleep apnea and was prescribed BiPAP after a sleep study and PAP titration. Visit notes of April 15, 2020 indicate the enrollee was using it about three hours per night, thus not meeting minimum usage. There was concern about a need for oxygen, so a repeat titration was done on May 21, 2020. That study showed BiPAP was effective and no need for oxygen. Compliance report January 14, 2021 to February 12, 2021 shows 0% of days with at least four hours per day usage. Subsequent visit notes did not identify any specific issues to address for improvement in compliance, other than urging the patient to use it. There is no medical necessity for a repeat PAP titration study. The problem is that the enrollee has been unable to use the device enough for it to be effective. There is no reason to expect that another titration study will change that. 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 re-titration for BIPAP. have not been met. Therefore, we decided that the Plan does not have to pre-approve re-titration for bilevel positive airway pressure (BIPAP).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the mental health evaluation to be provided by an out-of-network provider.
You asked the Plan to pre-approve the mental health evaluation. You say that you have not been sleeping well and it is affecting your daily life. You say that mental health is crucial, and you already went to Medicare to get help. The Plan denied your request. The Plan says care is available through your medical group. The Plan also says that you should contact your primary care physician for a referral.
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 the mental health evaluation to be provided by an out-of-network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vertiflex Superion Device.
You asked the Plan to pre-approve Vertiflex Superion Device. 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 Vertiflex Superion Device. 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 chronic low back pain. The Vertiflex device remains
experimental. More research is needed to show safety and efficacy of the device. 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 Vertiflex Superion Device have not been met. Therefore, we decided that the
Plan does not have to pre-approve Vertiflex Superion Device.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve specialist services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve specialist services. You say that you would like approval for these services to be provided out-of-network. 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 specialist services to be provided by an out of network (OON) provider.