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

We decided that the Plan does not have to pre-approve the teeth extractions services.
You asked the Plan to pre-approve the teeth extraction services. You say that the teeth must be removed prior to cardiac surgery in order to minimize the risk of infection. The Plan denied your request. The Plan says extraction of the teeth is not an integral part of the proposed cardiac care; therefore, 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 items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the teeth extractions services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional transportation mileage (A0170).
You asked the Plan to pre-approve the additional transportation mileage. You say that the additional mileage is needed to reach your doctor. The Plan denied your request. The Plan says trips are limited to 75 miles per trip. The request for 10 additional miles per trip exceeds the benefit's limit.
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 60 one-way trips per year, not to exceed 75 miles per trip. We looked at your request, the records in the case file, and the rules. The benefit is limited to 75 miles per trip. The request is for 10 additional miles, which exceeds the mileage provided in the benefit. Based on this information, we decided that the plan does not need to approve the additional mileage. Therefore, we decided that the Plan does not have to pre-approve additional transportation mileage (A0170).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia (J0897).
You asked the Plan to pre-approve Prolia. You say that this is medically necessary. The Plan denied your request. The Plan says step therapy criteria have not been met.
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 Prolia. Our reviewer says that the criteria for coverage of Prolia have not been met. Our physician reviewer found the Plan requires either a history of osteoporotic fracture or a trial of zoledronic acid before they will approve the requested drug. In this case, the patient has not tried and failed the required drug. The enrollee does not not have a history of osteoporotic fracture and the plan's required drug would not likely be less effective or have adverse effects for the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia (J0897).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hooks for a medical-necessities bag and a USB charger for a power wheelchair.
You asked the Plan to pre-approve bag hooks and a USB charger. You say that the requested items are medically necessary. The Plan denied your request. The Plan says rules for pre-approval have not been met because the requested items are optional convenience items not serving a medical purpose.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The items at issue in this appeal do not serve a purpose that is primarily medical in nature. Therefore, we decided that the Plan does not have to pre-approve hooks for a medical-necessities bag and a USB charger for a power wheelchair.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission and services.
You asked the Plan to pre-approve SNF services. You say that the enrollee cannot walk with a walker. The
Plan denied your request. The Plan says the service required can be received in a lower level of care.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve SNF services. Our physician reviewer
found that from a nursing perspective, the enrollee received oral medications and had stable vital signs. There
are no identifiable skilled nursing service needs. Regarding rehab services, the enrollee was at wheelchair level
for functional mobility and at a maximal assist level for transfers. Although there are identifiable skilled
therapy service needs, the enrollee does not require skilled nursing or therapy services on a daily basis. She
does not meet severity of illness or intensity of service criteria for an inpatient basis in a SNF setting.
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 services have not been met. Therefore, we decided that the Plan does not
have to pre-approve a skilled nursing facility (SNF) admission and services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional physical therapy (PT) services.
You asked the Plan to pre-approve the additional physical therapy. You say that the services are medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 physical therapy. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the enrollee has had extensive therapy for her condition and the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment. 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 physical therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve additional physical therapy (PT) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete upper denture (D5110).
You asked the Plan to pre-approve the upper denture. You say that you need your upper dentures replaced because you lost the set you have. The Plan denied your request. The Plan says this service can only be covered once every five years, and the Plan paid for this same denture service less than five years ago.
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 covered by this benefit more than once in five years. The Plan provided documentation that you had this item or service previously in February of 2018, which is less than five years ago. Therefore, we decided that the Plan does not have to pre-approve a complete upper denture (D5110).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Nifedipine.
You asked the Plan to pre-approve Nifedipine. You say that denying this medication for the enrollee will eventually lead to an amputation of his leg. The Plan denied your request. The Plan says this drug is not covered for the enrollee's condition by Medicare Part B.
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 Nifedipine.
Benefits for Nifedipine 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: 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 would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested item is not a covered benefit.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre Continuous Glucose Monitor (CGM).
You asked the Plan to pre-approve the Freestyle Libre CGM. You say that the Freestyle Libre CGM is preferred by the provider. The Plan denied your request. The Plan says the plan preferred CGM, Dexcom G6, has more advanced nighttime alerting features that would better meet the enrollee's needs and has not been tried by the enrollee.
The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred brands and manufacturers. We looked at the file and Medicare rules. No clinical documentation was provided to show that the plan's preferred CGM (Dexcom G6) was trialed or that it would be unsafe or ineffective for the enrollee. The only information provided was a note that the provider prefers the Freestyle brand, however, no rationale was provided. Based on this information, we decided that Medicare rules for coverage of the Freestyle Libre CGM
have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre Continuous Glucose Monitor (CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a radiofrequency ablation procedure (64625) of the sacroiliac joint.
You asked the Plan to pre-approve the radiofrequency ablation procedure. You say that the requested procedure is medically necessary. The Plan denied your request. The Plan says the ablation procedure requested is not covered under Medicare.
The Plan must follow Medicare rules. Medicare rules say that Radiofrequency ablation used for sacroiliac joint pain is considered not medically necessary and investigational whether performed using traditional, cooled, or pulsed radiofrequency. We looked at the file and Medicare rules. The procedure requested is an ablation of the sacroiliac joint. Medicare rules consider this service investigational and not medically necessary. Based on this information, we decided that Medicare rules for coverage of the radiofrequency ablation procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve a radiofrequency ablation procedure (64625) of the sacroiliac joint.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Freestyle Libre 14-day system (K0553, K0554).
You asked the Plan to pre-approve Freestyle Libre. You say that the enrollee needs the Freestyle Libre because she is a diabetic and needs to check her sugar levels but is unable to stick her own fingers. The Plan denied your request. The Plan says the enrollee does not meet the criteria as the records do not show that the enrollee takes insulin.
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 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. Based on this information, we decided that Medicare rules for coverage of Freestyle Libre have not been met. Therefore, we decided that the Plan does not have to pre-approve Freestyle Libre 14-day system (K0553, K0554).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex Superion device.

You asked the Plan to pre-approve a Vertiflex Superion device. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a 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 review indicates that there is no specific clinical rationale for the requested device. Evidence is lacking. Large well-designed studies in the peer review scientific literature comparing stand-alone use of Superion device to established surgical decompression are needed. Published studies do not demonstrate any long-term health outcome advantage with the use of Superion as an alternative to standard surgical treatment. The review indicates that the items/services at issue in this case 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 Medicare rules for coverage of a Vertiflex Superion device have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex Superion device.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed (93306) to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the transthoracic echocardiogram. You say that the medical records provided will show proof of medical necessity. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
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 echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed (93306) to be provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pre-approve the crown. We decided that the Plan does not have to pre-approve
the core build up.

You asked the Plan to pre-approve the crown. You say that the enrollee needs a replacement buildup and crown
on tooth number 14 in order to close the open contact between tooth number 14 and 15. The Plan denied your
request. The Plan says that crowns are not covered for cosmetic reasons or for closing gaps. The Plan also says
that the services do not meet the criteria for coverage.

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 decided that the Plan has to pre-approve the crown for tooth # 14.

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 crown for tooth # 14 is medically necessary. Our physician reviewer found replacement crown for
tooth # 14 meets the criteria for coverage due to the current defective crown. The reviewer found that the
provided documentation shows there is a lack of contact with the adjacent crown creating an open contact. The
reviewer found that the crown is medically reasonable and 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 crown have been met. Therefore, we decided that the Plan has to pre-approve
the crown for tooth # 14.

We also decided that the Plan does not have to pre-approve the core build up for tooth # 14.

Our reviewer also says the core build up for tooth # 14 is not medically necessary. The reviewer found that the
documentation does not support the need for a core buildup at this time.

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 core build up have not been met. Therefore, we decided that the Plan does
not have to pre-approve the core build up for tooth # 14.

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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a surgical placement of an eposteal implant (D6040),
custom fabricated abutment (D6057), and implant supported porcelain/ceramic crown (D6065).
You asked the Plan to pre-approve the surgical placement of an eposteal implant, custom fabricated abutment,
and implant supported porcelain/ceramic crown. The Plan denied your request. The Plan says these services are
not covered under the enrollee's 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-approve a
surgical placement of an eposteal implant (D6040), custom fabricated abutment (D6057), and implant
supported porcelain/ceramic crown (D6065).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips
You asked the Plan to pre-approve the additional trips. The Plan denied your request. The Plan says you have used all of the trips.
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 12 trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. The requested trips will exceed the benefit limit. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation trips
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that you are at risk for not regaining full function if you
are discharged to a lower level of care. The Plan denied your request. The Plan says this request is not
medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer found that
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. Our physician reviewer also found that there is not a
reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation
therapy program provided in an IRF.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute IRF admission and services.