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

We decided that the Plan does not have to pre-approvea left knee arthroscopy with lysis of adhesions for the enrollee.You asked the Plan to pre-approvethese services. 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 arthroscopic debridement and lavage with or without debridement for patients presenting with severe osteoarthritis is non-covered. We looked at the file and Medicare rules. The requested procedure is not covered by Medicare.Therefore, we decided that the Plan does not have to pre-approvea left knee arthroscopy with lysis of adhesions.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Power Scooter (K0800). You asked the Plan to pre-approve the scooter. You say that you need a smaller power scooter, as the one you have is too large and your walker no longer meets your needs.The Plan denied your request. The Plan says the record does not show that the enrollee can safely operate the power scooter within the home.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 the record does not include a safety assessment documenting that the PMD can be safely operated in the home. 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 Power Scooter (K0800).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approveRifton Tram (E1399).You asked the Plan to pre-approvethe RiftonTram. You say that the Rifton Tram is the device that will accommodate safe transfers. You have been using it on loan for a year and now you need to purchase one.The Plan denied your request. The Plan says this item is excluded and therefore is not covered by neither Medicare nor the plan.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at this the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Rifton Tram have not been met.Therefore, we decided that the Plan does not have to pre-approveRifton Tram (E1399).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional days of SNF care, for the enrollee.You asked the Plan to pre-approve SNF 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 Medicare pays for care in a SNF when the four factors listed above 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 based on available records, the patient does not meet criteria for coverage of SNF during the dates at issue. The records do not support that the enrollee needed continued daily physical therapy (PT) and occupational therapy (OT). There were no noted daily skilled complex nursing needs. While she may have benefited from continuing PT and OT, the records do not support the need for daily therapy during the dates at issue.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 additional days of SNF care, for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecontinued use of the Continuous Positive Airway Pressure (CPAP) device.You asked the Plan to pre-approvecontinued use of the CPAP device.You say that you are compliant with using the device.The Plan denied your request. The Plan says you have not been compliant with using the device.
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued use of the CPAP devicehave not been met.Therefore, we decided that the Plan does not have to pre-approvecontinued use of the Continuous Positive Airway Pressure (CPAP) device.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve F5 genetic testing for the enrollee. 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 testing is not covered.The Plan must follow Medicare rules. Medicare rules say that F5 gene testing is not medically necessary. The services at issue are F5 genetic testing. This testing is denied by Medicare as not medically necessary. Therefore, we decided that the Plan does not have to pre-approve F5 genetic testing for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvetooth extractions (41899) and dental anesthesia (00170).You asked the Plan to pre-approvetooth extractions and dental anesthesia. You say that the services are medically necessary.The Plan denied your request. The Plan says the requested services are not covered benefits with your plan.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approvetooth extractions (41899) and dental anesthesia (00170)
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecontinued use of a BiPAP device (E0470, E0562).You asked the Plan to pre-approvethe BiPAP device. You say that the BiPAP unit is medically necessary.The Plan denied your request. The Plan says records do not support ongoing coverage of the device.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 BiPAP device. Our reviewer says that coverage criteria has not been met. Our physician reviewer found the patient has not met the minimum usage criteria for the PAP device, of at least 4 hours per night for at least 70% of nights. There is no documentation of a recent clinical visit to address the compliance issue. The PAP device is considered not medically necessary because of insufficient usage.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 BiPAP device have not been met.Therefore, we decided that the Plan does not have to pre-approvecontinued use of a BiPAP device (E0470, E0562).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Dorsal Root Ganglion Stimulation Therapy (63650).
You asked the Plan to pre-approve the Dorsal Root Ganglion Stimulation Therapy. You say that this procedure is medically necessary. The Plan denied your request. The Plan says the documentation does not support the medical necessity or explain the plan for the member's current spinal cord stimulator.
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 Dorsal Root Ganglion Stimulation Therapy. 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 which is the subject of an ongoing clinical trial. 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 Dorsal Root Ganglion Stimulation Therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve Dorsal Root Ganglion Stimulation Therapy (63650).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve moderate sedation services during steroid injections.
You asked the Plan to pre-approve the sedation. You say that this is medically necessary. The Plan denied your request. The Plan says there is no medical need for sedation.
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 sedation. Our reviewer says that the requested sedation is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no indication for monitored anesthesia care to perform an epidural steroid injection. The request is not medically reasonable or necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the sedation have not been met. Therefore, we decided that the Plan does not have to pre-approve moderate sedation services during steroid injections.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve neuropsychological testing (96133, 96136 and 96137). You asked the Plan to pre-approve the neuropsychological testing. You say that you would like reconsideration as the testing is medically necessary. The Plan denied your request. The Plan says the records submitted did not show that the member needed these services.The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met.We looked at the file and Medicare rules. The record does not include sufficient information to determine whether the requested services are medically necessary. Based on this information, we decided that Medicare rules for coverage of the neuropsychological testing have not been met. Therefore, we decided that the Plan does not have to pre-approve neuropsychological testing (96133, 96136 and 96137).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a mandibular partial denture (D5214).You asked the Plan to pre-approve the dental item. You say that you want to appeal your original denial of the root canal and cap. You say that is better than getting a partial. You also say that they would just fix your tooth.The Plan denied your request. The Plan says the partial denture 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 dental item 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 dental item. Our reviewer says that the partial denture is not medically necessary. Our physician reviewer found the documentation does not provide any evidence of medical necessity for a mandibular removable partial denture because no mandibular teeth appear to be missing.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 dental item have not been met.Therefore, we decided that the Plan does not have to pre-approve a mandibular partial denture (D5214).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for additional non-emergency transportation trips.You asked the Plan to provide coverage for the additional non-emergency transportation trips. You say that the enrollee is seen in your office monthly and needs coverage for additional trips.The Plan denied your request. The Plan says the enrollee has exhausted the non-emergency transportation trips for the 2019 calendar year.Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 36 one-way trips per year. We looked at your request, the records in the case file, and the rules. The file shows that the enrollee used 36 transportation services from February 13, 2019 through September 12, 2019. Based on this information, we decided that the enrollee has exhausted the Plan maximum benefit for coverage of the additional non-emergency transportation trips.Therefore, we decided that the Plan does not have to provide coverage for additional non-emergency transportation trips.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by out of network provider.You asked the Plan to pre-approve these services. You say that the provider graduated from Harvard and you don't have to pay for parking.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 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 the medical services to be provided by out of network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a computed tomography (CT)scan of the heart for calcium screening.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 covered.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, a heart CT for calcium screening, is being 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 pre-approve a computed tomography (CT) scan of the heart for calcium screening.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a group 2 heavy duty power wheelchair (K0843). You asked the Plan to pay for the power wheelchair. You say that the enrollee's need for a power wheelchair is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet the coverage criteria. 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. 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 the power wheelchair. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation indicates the enrollee has a personal mobility deficit but the documentation is not consistent or clear that this deficit impairs mobility related activities of daily living.  The documentation is not consistent that the enrollee is unable to help her mobility deficit with a walker or an appropriately fitted manual wheelchair. Given multiple inconsistencies in the documentation the medical records do not indicate that a power wheelchair is 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 the power wheelchair have not been met. Therefore, we decided that the Plan does not have to pay for a group 2 heavy duty power wheelchair (K0843) to be provided by the provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aranesp. You asked the Plan to pre-approve Aranesp. The Plan denied your request. The Plan says that your provider has not said that Retacrit would not be as effective or would have adverse effects .Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Aranesp. Our reviewer says that Aranesp is not medically reasonable and necessary in this case. You have not failed to respond or had an adverse reaction to Retacrit. Our physician reviewer found that your condition does not meet criteria for coverage of Aranesp.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Aranesp have not been met. Therefore, we decided that the Plan does not have to pre-approve Aranesp.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve periodontal scaling and root planing (D4341), 4 or more teeth per quadrant, for the upper left, upper right, and lower right quadrants.You asked the Plan to pre-approve the dental services. The Plan denied your request. The Plan says the requested periodontal scaling and root planing 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 dental services 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 dental services. Our reviewer says that the periodontal scaling and root planing of 4 or more teeth per quadrant for the upper left, upper right, and lower right quadrants is not medically reasonable or necessary. Our physician reviewer found there were no periodontal chartings supplied with the records. The reviewer also found that the x-rays reveal only limited areas of bone loss or root calculus in any one quadrant, with less than four teeth affected. Therefore, the requested services are not medically reasonable or necessary.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 dental services have not been met.Therefore, we decided that the Plan does not have to pre-approve periodontal scaling and root planing (D4341), 4 or more teeth per quadrant, for the upper left, upper right, and lower right quadrants.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc-One for the enrollee. 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 enrollee has not tried and failed Orthovisc and Monovisc.Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has unilateral primary osteoarthritis of the right knee. He has not tried and failed the plan's required drugs of Orthovisc and Monovisc. 
The records do not show that these drugs would be less effective or contraindicated; therefore, Synvisc One 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 Synvisc-One for the enrollee
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genicular nerve ablation (64640).
You asked the Plan to pre-approve genicular nerve ablation. You say that you need this for pain. The Plan denied your request. The Plan says this service 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 genicular nerve ablation. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this is an experimental/ investigational procedure that is the subject of on-going clinical trials. This patient is not enrolled in a clinical trial. Therefore, it 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 genicular nerve ablation have not been met. Therefore, we decided that the Plan does not have to pre-approve genicular nerve ablation (64640).