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

We decided that the Plan does not have to pre-approve hearing aids to be provided by an out-of-network provider.

You asked the Plan to pre-approve hearing aids to be provided by an out-of-network provider. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says hearing aids are only covered when provided by a network provider.

Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when they are provided by a network provider. 

We looked at the file and the Plan's rules. The file shows you are requesting hearing aids to be provided by an out-of-network provider. The Plan only covers hearing aids when provided by a network provider. Based on this information, we decided that the Plan's rules for coverage of hearing aids have not been met. Therefore, we decided that the Plan does not have to pre-approve hearing aids to be provided by an out-of-network provider.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pre-approve a polysomnography.

You asked the Plan to pre-approve polysomnography; age 6 years or older, sleep staging with 4 or more additional parameters of sleep, attended by a technologist (95810). You say that the enrollee needs a polysomnography. The Plan denied your request. The Plan says that records submitted do not support the Plan's criteria.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 polysomnography; age 6 years or older, sleep staging with 4 or more additional parameters of sleep, attended by a technologist (95810). Our reviewer says that the requested service is considered medically reasonable and necessary in this case. Our physician reviewer found an attended polysomnography is considered reasonable and medically necessary for this enrollee. As documented in the medical record, the enrollee is shaky and weak after being treated with a prolonged course of steroids for suspected temporal arteritis. The enrollee has difficulty performing daily home activities. The ordering physician's assessment is that the enrollee will be unable to manage home polysomnography because of weakness and frailty. An attended polysomnography is needed for this enrollee, even though the enrollee does not have severe lung or heart disease. The denial is reversed. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of polysomnography; age 6 years or older, sleep staging with 4 or more additional parameters of sleep, attended by a technologist (95810) have been met. Therefore, we decided that the Plan has to pre-approve a polysomnography.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).

You asked the Plan to pre-approve a CGM. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says Medicare criteria 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 provided does not indicate that the enrollee performs blood glucose testing at least four times per day, uses insulin with at least three daily injections, and requires 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 a CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) and complete mandibular denture (D5120).

You asked the Plan to pre-approve the complete maxillary denture and complete mandibular denture. The Plan denied your request. The Plan says these services are not covered under 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-approve a complete maxillary denture (D5110) and complete mandibular denture (D5120).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve power operated vehicle, group 2 standard, patient weight capacity up to and including 300 pounds (K0806).

You asked the Plan to pre-approve power operated vehicle. You say that the item is medically necessary. The Plan denied your request. The Plan says your mobility limitation within the home can be sufficiently resolved with the use of a single point cane and you have also been approved for a 4-wheeled walker.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of power operated vehicle have not been met. Specifically, records show you are able to effectively use a cane or walker. This means the use of a power operated vehicle is not medically necessary. Therefore, we decided that the Plan does not have to pre-approve power operated vehicle, group 2 standard, patient weight capacity up to and including 300 pounds (K0806).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an occipital nerve block injection.

You asked the Plan to pre-approve injection(s), anesthetic agent(s) and/or steroid; greater occipital nerve (64405) and injection, betamethasone acetate 3 mg and betamethasone sodium phosphate 3 mg (J0702). You say that the enrollee needs the injection for pain relief. The Plan denied your request. The Plan says this procedure is not proven to be helpful for the enrollee's condition.

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 injection(s), anesthetic agent(s) and/or steroid; greater occipital nerve (64405) and injection, betamethasone acetate 3 mg and betamethasone sodium phosphate 3 mg (J0702). Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found in this case the member has been referred for occipital nerve blocks. The literature on the overall efficacy/utility of occipital nerve blocks for the treatment of occipital neuralgia remains limited. The studies published to date have shown weak and conflicting findings and it cannot be said that this service is superior to placebo or other therapeutic modalities. Furthermore, multiple studies have failed to show a conclusive benefit from the use of greater occipital nerve blocks in both the acute treatment of migraines and other types of headaches as well as a lack of a beneficial prophylactic effect. Rather, the current prevailing opinion in the literature is that further rigorous studies are needed of this procedure/technique in order to guide/permit conclusions. In this setting, given the need for further study, this service would not satisfy the Medicare definition of medical necessity and it would not be reasonable and 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 injection(s), anesthetic agent(s) and/or steroid; greater occipital nerve (64405) and injection, betamethasone acetate 3 mg and betamethasone sodium phosphate 3 mg (J0702) have not been met. Therefore, we decided that the Plan does not have to pre-approve an occipital nerve block injection.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a combination sit to stand system (E0637).

You asked the Plan to pre-approve a combination sit to stand system. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says a combination sit to stand system is not covered by Medicare or the Plan.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.

The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a combination sit to stand system (E0637).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Nurtec for the enrollee.

You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says the medication falls under Part D coverage.

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 Nurtec for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc-one (J7325).

You asked the Plan to pre-approve Synvisc-one. 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 Synvisc-one. Our reviewer says that the criteria for coverage of Synvisc-One have not been met. Our physician reviewer found the Plan requires a trial of drug Orthovisc and Monovisc before they will approve the requested drug. In this case, the patient has not tried and failed the required drugs. There is no documentation provided indicating that the Plan's required drugs would 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 Synvisc-one have not been met. Therefore, we decided that the Plan does not have to pre-approve Synvisc-one (J7325).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve positioning cushion/pillow/wedge, any shape or size, includes all components and accessories (E0190).

You asked the Plan to pre-approve positioning cushion. You say that need this item to help ease the pain of your wound without aggravating the wound. The Plan denied your request. The Plan says Medicare does not cover comfort or convenience items, hygienic equipment, nor items not primarily medical in nature. Medicare does not cover bathtub seats and therefore does not cover items associated with the non-covered item.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. 

The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve positioning cushion/pillow/wedge, any shape or size, includes all components and accessories (E0190).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a maxillary partial denture with dental code D5211.

You asked the Plan to pre-approve dental code D5211. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says upper partial dentures are covered once every five plan years. The Plan says that you received upper partial dentures, which is 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.

We looked at the file, the Plan's contract and Medicare rules. The Plan covers upper partial dentures once every five plan years. The file shows that the Plan approved and paid for upper partial dentures, which is less than five years ago. Therefore, we decided that the Plan does not have to pre-approve a maxillary partial denture with dental code D5211.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 3 power wheelchair (PWC).

You asked the Plan to pre-approve a group 3 power wheelchair. You say that you have been without your power chair since an accident. You say that you have been trying to get a replacement since then. The Plan denied your request. The Plan says the records provided do not show that the enrollee has a medical need for power tilt or power recline.

The Plan must follow Medicare rules. The rules say that a Group 3 PWC with single power option or multiple power options are only covered if a power tilt and recline seating system is reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. 

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 a group 3 power wheelchair. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found that the single power option included with K0856 group 3 power wheelchair with single power options is not medically necessary. The documentation does not reveal evidence of a need for a special drive control or power tilt or recline. The documentation does not reveal the enrollee uses intermittent catheterization, has spasticity that needs management with a power seating system, or that the enrollee cannot perform an independent weight shift.

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 Group 3 PWC with a single power option have not been met. Therefore, we decided that the Plan does not have to pre-approve a group 3 power wheelchair (PWC).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Superion Interspinous Spacer procedure.

You asked the Plan to pre-approve Insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level (22869). You say that the Superion Vertiflex Implant would provide significant clinical and quality of life benefits for the enrollee. The Plan denied your request. The Plan says a review of the current medical literature indicates that this service is considered experimental and investigational.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level (22869). Our reviewer says that the Superion interspinous spacer (Vertiflex device) is not medically reasonable or necessary, for treatment of this enrollee's medical condition. Our physician reviewer found current evidence based medical guideline and peer reviewed literature do not fully support the spinal decompression device procedure over the 'gold standard' of lumbar laminectomy. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of this device for this enrollee's medical condition as discussed above. FDA indications include implantation of the Superion device at one or two adjacent lumbar levels in patients with moderate spinal stenosis in whom operative treatment is indicated at no more than two levels, from L1 to L5. This enrollee has at least moderate spinal stenosis at L2-3, L3-4, L4-5, and L5-S1, and would not meet FDA indications. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level (22869) have not been met. Therefore, we decided that the Plan does not have to pre-approve a Superion Interspinous Spacer procedure.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex device.

You asked the Plan to pre-approve a Vertiflex device. You say that the requested Vertiflex device is medically necessary. The Plan denied your request. The Plan says the requested Vertiflex device is not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a Vertiflex device. Our reviewer says that the requested Vertiflex device is not medically necessary. Our physician reviewer found the enrollee is with spinal stenosis. The requested Vertiflex device is experimental. More research is needed to show safety and efficacy. Therefore, the requested Vertiflex device is not medically reasonable and 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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an additional dental cleaning.

You asked the Plan to pre-approve the additional dental cleaning. You say that you would like to receive a third cleaning each year. The Plan denied your request. The Plan says your plan only allows for two dental cleanings per year.

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 an additional dental cleaning.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided on May 23, 2019.

You asked the Plan to pay for the physician services. You say that the physician treated the enrollee in good faith. The Plan denied your request. The Plan says the claim was untimely.

The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. 

The record shows that a claim for the physician services was not filed until September 24, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the physician services provided on May 23, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.

You asked the Plan to pre-approve foot orthotics. The Plan denied your request. The Plan says this item is not a covered benefit.

Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. 

Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician services to be provided by an out of network provider.

You asked the Plan to pre-approve physician services with an out of network provider. You say that you had a bad experience at the clinic you were directed to. The Plan denied your request. The Plan says your care can be transitioned to a contracted provider.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve physician services to be provided by an out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.

You asked the Plan to pre-approve foot orthotics. You say that you are requesting an appeal. The Plan denied your request. The Plan says this item is not a covered benefit.

Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. 

Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.