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

We decided that the Plan does not have to pre-approve an unspecified preventive service (D1999).

You asked the Plan to pre-approve the unspecified preventive service. You say that you were advised by a plan representative that you were in network. You say that this should be reprocessed as in network. The Plan denied your request. The Plan says unspecified preventive service is not listed as a covered service.

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 unspecified preventive service (D1999).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and supplies.

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 does not meet the criteria for coverage.

The Plan must follow Medicare rules. Medicare rules say that a therapeutic CGM is covered when specific criteria are met. 

We looked at the file and Medicare rules. The records show that the enrollee is not insulin-treated. 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 continuous glucose monitor (CGM) and supplies.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the PureWick external catheter system.
You asked the Plan to pre-approve incontinence supplies. You say that this is medically necessary. The Plan
denied your request. The Plan says this is not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered
because they are hygienic items that are non-reusable.
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of
these items. Therefore, we decided that the Plan does not have to pre-approve the PureWick external catheter
system.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a prosthetic leg with an advanced foot and ankle feature
(L5981, L5968).

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your
request. The Plan says a request for K3 foot does not meet the criteria as reasonable and 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 the services. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found the request appears to exceed your medical need as the treating medical APRN progress notes do not
support that you are a K3 ambulator.

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 services have not been met. Therefore, we decided that the Plan does not
have to pre-approve a prosthetic leg with an advanced foot and ankle feature (L5981, L5968).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied
your request. The Plan says daily skilled services are no longer required.
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 the admission. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found you no longer qualify for SNF coverage.
You do not have documented skilled nursing or skilled therapy needs. Daily skilled services are not required to
establish a maintenance program or to prevent deterioration of your condition. Your care needs at this point are
custodial and, as a practical matter, can be provided at a lower level of care.
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 admission have not been met. Therefore, we decided that the Plan does not
have to pre-approve continued admission to a skilled nursing facility (SNF).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI), brain (including
brain stem) (70553).
You asked the Plan to pre-approve the MRI. You say that the medical records provided support the necessity of
the services in dispute. The Plan denied your request. The Plan says the medical records do not support that the
MRI of the brain is not medically necessary at this time.
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 the MRI. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found the enrollee underwent an MRI in July 2020. The enrollee is currently receiving treatment for
his condition. The prescriber indicated in a note March 2021 that there has been no clinical change and
requested an MRI stating that "there would have to be significant changes" in order for the MRI to result in a
change in treatment. The provided documentation does not support the medical necessity or reasonableness of
the requested service 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 the MRI have not been met. Therefore, we decided that the Plan does not have
to pre-approve magnetic resonance imaging (MRI), brain (including brain stem) (70553).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the power seat elevation system (E2300).
You asked the Plan to pre-approve the power seat elevation system. You say that you would like this claim reprocessed for medical necessity. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature is not a covered benefit. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the power seat elevation system have not been met. Therefore, we decided that the Plan does not have to pre-approve the power seat elevation system (E2300).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core build up (D2950) for tooth # 14.
You asked the Plan to pre-approve the dental service. You say that the core build up is necessary. The Plan denied your request. The Plan says core build up is not listed as a covered service.
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 core build up (D2950) for tooth # 14.
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 these orthotics are medically necessary for your foot and ankle pain. 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment with Pegfilgrastim-cbqv (Q5111).
You asked the Plan to pre-approve Pegfilgrastim-cbqv. You say that the requested treatment is a medical
necessity for the enrollee. The Plan denied your request. The Plan says the requested drug is not reasonable and
necessary.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer
drugs if they are medically accepted as safe and effective or appropriate for the particular use.
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 Pegfilgrastim-cbqv. Our reviewer says
that the requested drug is not medically reasonable and necessary. Our physician reviewer found that the
enrollee has myelodysplastic syndrome treated with Vidaza. The requested use of Pegfilgrastim-cbqv is not
FDA-approved for the enrollee's diagnosis. Pegfilgrastim-cbqv is FDA approved for patients with non-myeloid
malignancies receiving myelosuppressive cancer chemotherapy associated with a clinically significant
incidence of febrile neutropenia. Myelodysplastic syndrome is a myeloid malignancy. The use is not supported
by one of the major drug compendia or by clinical research that appears in a Medicare-approved medical
journal. Guidelines for Vidaza recommend dose reductions for neutropenia.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Pegfilgrastim-cbqv have not been met. Therefore, we decided that the Plan does
not have to pre-approve treatment with Pegfilgrastim-cbqv (Q5111).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor.
You asked the Plan to pre-approve a therapeutic continuous glucose monitor. You say that this item is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the criteria for a therapeutic continuous glucose have not been met.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a therapeutic continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable controller with harness upgrade, calf pad, adjustable angle foot plates, and elevating leg rests for a power wheelchair (PWC).

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 must follow Medicare rules. Medicare rules say that an expandable controller with harness is needed to control three or more power options. The rules say that Medicare does not cover equipment that serves the same purpose as other equipment already available to an enrollee. 

We looked at the file and Medicare rules. The requested expandable controller and harness is not covered because it is not needed to control one power option in the approved PWC. The calf pads, adjustable foot plates, and elevating leg rests are not covered because they are already approved in the base PWC and are therefore duplicate items. Therefore, we decided that the Plan does not have to pre-approve an expandable controller with harness upgrade, calf pad, adjustable angle foot plates, and elevating leg rests for a power wheelchair (PWC).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion of a lumbar interspinous process stabilization device.
You asked the Plan to pre-approve insertion of a lumbar interspinous process stabilization device. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve insertion of a lumbar interspinous process stabilization device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has lumbar spinal stenosis. The interspinous process devices remain experimental. More research is needed to show safety and efficacy. Therefore, the enrollee does not meet criteria for the requested services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of insertion of a lumbar interspinous process stabilization device have not been met. Therefore, we decided that the Plan does not have to pre-approve insertion of a lumbar interspinous process stabilization device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the transit system (K0108).
You asked the Plan to pre-approve the transit system. You say that you would like the Plan's denial
reconsidered. The Plan denied your request. The Plan says this is not a covered service.
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate
and needed for use inside the home.
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not
have to pre-approve the transit system (K0108).
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 a power scooter. You say that you do not understand why this was denied.
The Plan denied your request. The Plan says the records show that your current wheelchair allows you to be
fully functional within your home.

The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered
reasonable and necessary. The rules also state that for equipment to be covered, it must be appropriate and
needed for use inside the home.

The file shows that you have a wheelchair, which serves the same purpose as a power scooter. The record also
shows that a power wheelchair was requested for you to go on walks outside. Although this item may be
helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that
the Plan does not have to pre-approve a power scooter (K0800).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee can stay in the hospital to receive treatment.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone replacement grafts (D4263 x10), osseous surgery (D4260 x4), biological materials to help healing (D4265 x3), and other drugs and/or medicine (D9630).

You asked the Plan to pre-approve bone replacement grafts, osseous surgery, biological materials to help healing, and other drugs and/or medicine. You say that the services are medically necessary. The Plan denied your request. The Plan says the services at issue are not covered benefits.

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 bone replacement grafts (D4263 x10), osseous surgery (D4260 x4), biological materials to help healing (D4265 x3), and other drugs and/or medicine (D9630).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve prosthetic repair of shoulder joint for the enrollee.
You asked the Plan to pre-approve the surgery. You say that this is medically necessary, as the enrollee has
now done six weeks of treatment and an MRI. The Plan denied your request. The Plan says there is insufficient
documentation of six weeks of a trial and failure of conservative management.
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 surgery. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found detailed documentation is not evident regarding at least 6 weeks of a trial and failure of recent,
reasonable and comprehensive less invasive conservative care measures. The requested surgical procedure is
not recommended prior to failure of such conservative measures. There is no compelling rationale presented or
extenuating circumstances noted to support the medical necessity of this request as an exception to criteria.
Therefore, the request for prosthetic repair of shoulder joint 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 surgery have not been met. Therefore, we decided that the Plan does not
have to pre-approve prosthetic repair of shoulder joint for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an allowance for transportation for non-medical needs, healthy food purchases and/or electricity, water and/or phone bill payments (debit card), home assistance services (repairs).
You asked the Plan to pre-approve the allowance for transportation for non-medical needs, healthy food purchases and/or electricity, water and/or phone bill payments (debit card), home assistance services (repairs).. You say that The Plan denied your request. The Plan says you do not have a qualifying diagnosis, you do not require intensive care coordination and you do not have a high risk for hospitalizations or high risk for adverse health outcomes.
The Plan contract says that, in order to be eligible for an allowance, you must have one or more comorbid and medically complex chronic conditions that are life-threatening or significantly limit your health or general functioning. In addition, you must have a high risk of hospitalization or other adverse health outcomes; and must require intensive care coordination.
We looked at the file and Plan's rules. The file shows that your medical conditions are not eligible medical conditions under the Plan's benefit. Therefore, we decided that the Plan does not have to pre-approve an allowance for transportation for non-medical needs, healthy food purchases and/or electricity, water and/or phone bill payments (debit card), home assistance services (repairs).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a new artificial leg.

You asked the Plan to pre-approve the leg. You say that this is medically necessary. The Plan denied your
request. The Plan says the request for a new transtibial prosthetic socket does meet Medicare criteria as
reasonable and 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 the leg. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found the requested item appears to exceed your medical need. The documentation does not provide adequate
documentation of functional and/or physiological need for a replacement shower leg prosthesis.

There is no evidence that you require special protection from harsh environmental situations or that the patient requires an additional prosthesis with specialized weatherproofing protection. There is no evidence of damage to the current prosthesis. 

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 leg have not been met. Therefore, we decided that the Plan does not have to pre-approve a new artificial leg.