Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe Tysabri infusions tobe provided by out of network (OON) provider, "the medical center".You asked the Plan to pre-approvethe OON services. You say that this OON facility is the nearest location which is able to provide Tysabri infusions.The Plan denied your request. The Plan says there is a nearby in-network facility that is able to provide this treatment.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services.Therefore, we decided that the Plan does not have to pre-approvethe Tysabri infusions to be provided by out of network (OON) provider, "the medical center".
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a stress transthoracic echocardiogram (TTE).
You asked the Plan to pre-approve these services. You say that the services are medically necessary. 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 records show that you have some cardiac risk with mild increased muscle growth (hypertrophy) and mild valvular disease. There is no documented cardiac physical exam abnormalities on a recent treadmill electrocardiogram (EKG). You are clinically stable with an echocardiogram one year prior. A repeat TTE is not reasonable or medically necessary at this time. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a stress transthoracic echocardiogram (TTE).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve outpatient physical therapy. You asked the Plan to pre-approve physical therapy. You say that physical therapy has helped improve the enrollee's quality of life. The Plan denied your request. The Plan says the denial of authorization for these services is correct, because physical therapy is not medically necessary for the enrollee at this time.The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage for any service, the information submitted by the provider must corroborate the documentation in the beneficiary's medical record and confirm that Medicare coverage criteria have been met. The provider must furnish to the Plan sufficient information to determine whether service is covered. We looked at the file and Medicare rules. No medical records have been submitted to the Plan to support this request for coverage. The Plan attempted to obtain medical records but not were furnished. Without this information, this request for coverage of physical therapy is not supported. Medical documentation should be submitted to the Plan to support coverage of this request. Based on this information, we decided that Medicare rules for coverage of physical therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve outpatient physical therapy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 2 Power Operated Vehicle (POV). You asked the Plan to pre-approve the POV. You say that the POV is medically necessary for the enrollee.The Plan denied your request. The Plan says Group 2 POV's are non-covered under Medicare rules.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. Group 2 PMD's have features designed for use outside the home, and therefore are non-covered.The file shows that the type of Power Operated Vehicle being requested has features for use outside the home, and therefore, is not covered under Medicare rules. 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 2 Power Operated Vehicle (POV).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an MRI of the lower extremity.You asked the Plan to pre-approve an MRI of the lower extremity. You say that the requested MRI of the lower extremity is medically necessary.The Plan denied your request. The Plan says the requested MRI of the lower extremity is not medically necessary.The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve an MRI of the lower extremity. Our reviewer says that the requested MRI of the lower extremity is not medically necessary. Our physician reviewer found this enrollee presents with a 6 to 7-month history of right lower leg/calf pain with weight bearing activities. He reports proximal/medial calf pain with numbness and tingling. Clinical exam findings document weak right lower extremity pulses, mild bilateral lower extremity swelling, and decreased sensation in a stocking glove pattern. X-rays of the right tibia/fibula apparently show no tibial shaft abnormalities but do evidence vascular calcifications. He has radiographic evidence of moderate to advanced right knee lateral compartment osteoarthritis. A corticosteroid injection to the right knee on 10/4/19 resulted in 20-30% reduction in his symptoms. A right knee MRI has been recommended and approved. It is opined that he could have some peripheral vascular disease and these could be symptoms of claudication. A right lower extremity MRI has been recommended to rule-out any structural abnormalities. He has been referred to a vascular surgeon for evaluation. Under consideration is a request for right lower extremity MRI. Current evidence based medical guidelines do not recommend right lower extremity MRI as an initial evaluation for vascular claudication. There are no structural lower leg/calf findings on x-rays or significant orthopedic lower leg/calf findings on clinical exam to support the medical necessity of MRI. Comprehensive detailed non-operative treatments have not been documented. MRA and or ultrasound have not been documented as non-applicable. Therefore, this request for right lower extremity MRI is not medically reasonable and necessary for this enrollee's medical condition at this time.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an MRI of the lower extremity have not been met.Therefore, we decided that the Plan does not have to pre-approve an MRI of the lower extremity.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued use of the stationary oxygen concentrator.You asked the Plan to pre-approve the stationary oxygen concentrator. You say that the enrollee needs the stationary oxygen concentrator. The Plan denied your request. The Plan says the enrollee has not been compliant with the stationary oxygen concentrator and the oxygen saturation level does not meet criteria.The Plan must follow Medicare rules. The rules say that for patients with arterial PO2 at or above 60 mm Hg or arterial O2 saturation at or above 90%, there is a rebuttable presumption of non-coverage for home oxygen.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the stationary oxygen concentrator have not been met.Therefore, we decided that the Plan does not have to pre-approve continued use of the stationary oxygen concentrator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprove a pneumatic compression device (E0652).You asked the Plan to preapprove a pneumatic compression device. You say that the enrollee requires the device.The Plan denied your request. The Plan says the documentation did not support the 4-week trial using the basic pump that Medicare requires.The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 orE0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required.We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided.Therefore, we decided that the Plan does not have to preapprove a pneumatic compression device (E0652)
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided on July 29, 2019.You asked the Plan to pay for the physician services. You say that you would like the plan to reconsider their denial of payment.The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network care.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 pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay for the physician services provided on July 29, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the porcelain crown (D2751) for tooth #9.You asked the Plan to pre-approve the crown on tooth #9. You say that you need the crown because your tooth is loose and the dentist always has to shave it down. You say it costs more to shave the tooth down than fix it with a crown. The Plan denied your request. The Plan says the service is not medically necessary.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. The Plan covers the crown on tooth #9 when the services are medically necessary and reasonable. 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 crown on tooth #9. Our reviewer says that the crown is not medical necessary. Our physician reviewer found the dental record and x-rays do not indicate that there is significant breakdown of tooth #9 due to caries or fracture. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the crown on tooth #9 have not been met. Therefore, we decided that the Plan does not have to pre-approve a porcelain crown (D2751) for tooth #9.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveZolpidem Tartrate.You asked the Plan to pre-approveZolpidem Tartrate. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says Zolpidem Tartrate is not covered under the enrollee's Medicare Part B 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-approveZolpidem Tartrate.Benefits for Zolpidem Tartratemay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveTramadol HCL 50 MG tablets.You asked the Plan to pre-approveTramadol tablets. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says Tramadol tablets are not covered under the enrollee's Medicare Part B 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 whichare covered by Medicare Part B.Therefore, we decided that the Plan does not have to pre-approveTramadol HCL 50 MG tablets.Benefits for Tramadol tabletsmay be available under Medicare Part D.Contactthe 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 acupuncture services You asked the Plan to pre-approve the acupuncture services. You say that you would like reconsideration as these services have been helpful in the past. The Plan denied your request. The Plan says acupuncture is not a covered benefit.The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare.The services at issue in this appeal are acupuncture services. Therefore, we decided that the Plan does not have to pre-approve acupuncture services
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveHorizant ER 600 MG tablets.You asked the Plan to pre-approveHorizant tablets. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says Horizant tablets are not covered under the enrollee's Medicare Part B benefit.The Plan must follow Medicare rules. The rules say that Medicare Part B generally doesnot 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-approveHorizant ER 600 MG tablets.Benefits forHorizant tabletsmay be available under Medicare Part D.Contactthe 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-approveendodontic therapy for tooth #5.You asked the Plan to pre-approveendodontic therapy for tooth #5. You say that the root canal is necessary so the tooth can be saved.The Plan denied your request. The Plan says this is 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 itemsor services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approveendodontic therapy for tooth #5.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the periodontal scaling and root planing (D4341 x4).You asked the Plan to pre-approve the periodontal scaling and root planing (D4341 x4). You say that you would like the deep cleaning to be covered in order to avoid needing more teeth pulled and dentures in the future.The Plan denied your request. The Plan says the services are a covered benefit, but the limit is exhausted.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, there is a benefit limit for the periodontal scaling and root planing (D4341 x4). The plan clearly states that only one periodontal scaling and root planing (D4341 x4)procedure is covered every 2 years. The records show the Plan paid for periodontal scaling and root planing (D4341 x4) on July 27, 2019 and August 6, 2019, which exhausted the benefit.Therefore, we decided that the Plan does not have to pre-approve the periodontal scaling and root planing (D4341 x4).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network provide.You asked the Plan to pre-approve the referral. You say that you feel that these services are medically necessary.The Plan denied your request. The Plan says the rendering provider is out-of-network.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services.Therefore, we decided that the Plan does not have to pre-approve a referral to the out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve enteral nutrition, metabolic formula  (B4153).You asked the Plan to pre-approve the enteral nutrition. You say that you are requesting reconsideration to improve your health, have a better quality of life and to avoid having a surgery.The Plan denied your request. The Plan says enteral nutrition as oral supplement between meals is not covered.The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation.The items you asked The Plan to pre-approve are nutritional supplements. Therefore, we decided that the Plan does not have to pre-approve enteral nutrition, metabolic formula  (B4153).
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve a change in dose of Rituxan (J9312) to 1g every 4 months. You asked the Plan to pre-approve the change in dose of Rituxan. You say that you would like to taper the member down from the standard dose. The Plan denied your request. The Plan says that the documentation did not provide rationale for increasing Rituxan from every 6 months to every 4 months. The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 change in dose of Rituxan. Our reviewer says that the enrollee's dose has been 2gm every 6months. The enrollee has done well on this dose, prompting her and her provider to try to decrease the dose. The provider has recommended a taper where rather than receiving 2gm every 6 months, the enrollee is to receive 1gm every 4 months. Our physician reviewer found this would effectively decrease the enrollee's dose from 4gm over the next 12 months to 3gm over the next 12 months. Literature does not note a consensus on how much drug, or for how long the drug, should be provided as maintenance dosing. Given this enrollee's history and available literature, the provider's approach appears to be reasonable. 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 change in dose of Rituxan have not been met. Therefore, we decided that the Plan has to pre-approve a change in dose of Rituxan (J9312) to 1g every 4 months. 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SI joint injections (64640).You asked the Plan to pre-approve the SI joint injections. You say that the SI joint injections have had positive results for the member in the past. The Plan denied your request. The Plan says this treatment does not improve outcomes compared to standard treatments.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 SI joint injections. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this is an experimental/ investigational procedure because of the wide variation in efficacy reported in the peer reviewed literature.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 SI joint injections have not been met. Therefore, we decided that the Plan does not have to pre-approve SI joint injections (64640).