Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hypoglossal nerve stimulation device coded as 0466T and 64568You asked the Plan to pre-approve the hypoglossal nerve stimulation device. You say that you have provided medical records to further support the medical necessity of the inspire therapy.The Plan denied your request. The Plan says this request has not been established as an effective option and is not covered by Medicare.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 physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the hypoglossal nerve stimulation device have not been met.Therefore, we decided that the Plan does not have to pre-approve Hypoglossal nerve stimulation device coded as 0466T and 64568
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea mini hand bike.You asked the Plan to pre-approvea mini hand bike. You say that a mini hand bike would help the enrollee to exerciseand become healthier.The Plan denied your request. The Plan says exercise equipment is not primarily medical in nature and is excluded from coverage under Medicare.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily servea 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-approvea mini hand bike
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the replacement lower partial denture (D5214) to be provided by the provider.
You asked the Plan to pre-approve the denture. You say that you want to appeal the decision to denial coverage for partial dentures. The Plan denied your request. The Plan says the benefit limit has been exhausted.
Medicare generally does not cover dental services. The Plan follows the same rule. Replacement of removable and fixed prostheses is covered once every 5 years. Records show that you had this service on November 7, 2018. The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve the replacement lower partial denture (D5214) to be provided by the provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approveincontinence supplies.You asked the Plan to pre-approveincontinence supplies. You say that you cannot afford the necessary incontinence supplies and would like the Plan to cover them.The Plan denied your request. The Plan says this item 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-approveincontinence supplies.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan doesnot have to pre-approve hearing aids to be provided by the provider.You asked the Plan to pre-approve the hearing aids to be provided. You say that you have tried hearing aids from the Plan's provider with unsatisfactory results. The Plan denied your request. The Plan says the supplemental hearing aid benefit is exclusively and specifically for hearing aids provided.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 provided.We looked at the file and the Plan's rules.The requested provider in this case is not a network hearing aid provider with the Plan.Therefore, we decided that the Plan does not have to pre-approve the requested hearing aids.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF)admission and services.You asked the Plan to pre-approveIRF care. You say that the records provided support the need for IRF care.The Plan denied your request. The Plan says the guidelines for coverage have not been met.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.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 enrollee does not require the intensity of services provided at an IRF. Our physician reviewer found that the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. Our physician reviewer found that the enrollee willbe restricted due to his weight-bearing limitations. Our physician reviewer found that the enrollee's care needs can be met 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 IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecompression stockings identified with code A6545.You asked the Plan to pre-approvethe compression stockings. The Plan denied your request. The Plan says the coverage criteria are not met.The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6545 are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that compression bandages and gradient compression wraps are covered only when they are used as dressings over a qualifying wound.The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you do not have a medical condition for which compression stockings can be covered or paid for by Medicare.Therefore, we decided that the Plan does not have to pre-approvecompression stockings identified with code A6545.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Acthar injections (80units every 72 hours).
You asked the Plan to pre-approve the Acthar injections. You say that this is a medically necessary drug. The Plan denied your request. The Plan says this drug is for self-injection. This would be covered by Medicare Part D.
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 Acthar injections (80units every 72 hours).
Benefits for the Acthar injections 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveadditional skilled nursing facility (SNF) care.You asked the Plan to pre-approvethe additional days of SNF care. You say that additional rehab is needed for work on getting up and down from a chair and walking. You say that the rehab facility is making sure physical and occupational therapy services are provided. You say that you want to ensure safety when it comes time to return home.The Plan denied your request. The Plan says the SNF benefit has been exhausted as of December 24, 2019.The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and ends when the enrollee has gone60 days in a row without inpatient hospital or SNF care. The file shows that you received 100 days of SNF care during the benefit period from May 17 -December 24, 2019. The Plan has covered 100 days of SNF care.Although you may still need skilled care, the Plan is not required to pay for more than 100 days of SNF coverage during this benefit period. You will be eligible for a new benefit period when you have not been receiving care in a hospital or skilled care in a SNF for at least 60 days in a row.Therefore, we decided that the Plan does not have to pre-approveadditional skilled nursing facility (SNF) care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee does not have rehabilitation, medical or nursing needs alone or together that represent the complexity or intensity of service necessary to meet Medicare admission requirements for an IRF.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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 enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to be able to perform fifteen hours per week of rehabilitative services with regular physician evaluation. The enrollee's care needs can be met at a lower level of care (ex. SNF/SAR). 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 admission to an inpatient rehabilitation facility (IRF) for enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe True Metrix diabetic test strips to be provided by a retail pharmacy.You asked the Plan to pre-approvethe True Metrix diabetic test strips through a retail pharmacy. You say that the enrollee has been using the True Metrix test strips and prefers themfor ease of use, availability, affordability, and consistent readings. The Plan denied your request. The Plan says the True Metrix test strips are available through local contracted provider or mail order but not at a retail pharmacy.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan only has to pre-approve preferred test strips from a retail pharmacy or mail-order. The requested test strip brand is not a preferred brandwith the Plan. We found no exception that would require the Plan to pre-approve these items at a retail pharmacy.Therefore, we decided that the Plan does not have to pre-approvethe True Metrix diabetic test strips to be provided by a retail pharmacy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair.You asked the Plan to pre-approve a power wheelchair. You say that it takes you longer to do things and need a power wheelchair to get home faster to your wife.The Plan denied your request. The Plan says that you do not meet criteria for coverage of a power wheelchair.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 a power wheelchair.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc injection. You asked the Plan to pre-approve the injection. You say that this is medically necessary.The Plan denied your request. The Plan says step therapy guidelines were not followed.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 the injection. Our reviewer says that the requested injection is not medically reasonable or necessary. Our physician reviewer found the provided medical records do not indicate that the enrollee has tried and failed the required drugs. The provided medical records do not indicate that the Plan's required drugs would likely be less effective and/or likely 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 the injection have not been met.Therefore, we decided that the Plan does not have to pre-approve Synvisc injection.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approveProlia for "the beneficiary".You asked the Plan to pre-approvethese services. You say that the enrollee has failed bisphosphonates.The Plan denied your request. The Plan says the step therapy requirement is not 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has age-related osteoporosis without current pathological fracture. She has been on oral bisphosphonates of Actonel and alendronate. The records show that the enrollee has not tried and failed the plan's required drug of zoledronic acid. The recorsd do not show that the zoledronic acid would be less effective or contraindicated; therefore, Prolia 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-approveProlia for "the beneficiary".
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea CPAP battery backup.You asked the Plan to pre-approvea CPAP battery backup. You say that the power goes out sometimes and you cannot sleep without your CPAP.The Plan denied your request. The Plan says CPAP battery backups are precautionary and therefore 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-approvea CPAP battery backup.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not haveto pre-approve surgical bone shaping and gingival irrigation.You asked the Plan to pre-approve the dental services. You say that this is medically necessary.The Plan denied your request. The Plan says this is not a covered benefit.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approve surgical bone shaping and gingival irrigation.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveTravatan 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 self-administered drugs are not covered.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-approveTravatan for the enrollee.Benefits for these servicesmay be available under Medicare Part D.Contactthe 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-approvea backup battery for your portable oxygen concentator.You asked the Plan to pre-approvea backup battery. You say that you need a second battery in case you run out of battery you will run out of oxygen.The Plan denied your request. The Plan says that this is not covered by Medicare.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 file shows that you have a battery. A battery serves the same purpose as a backup battery.Therefore, we decided that the Plan does not have to pre-approvea backup battery for your portable oxygen concentator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve repairs to your manual wheelchair.
You asked the Plan to pre-approve repairs to your manual wheelchair. You say that you use a manual wheelchair at outdoor events. The Plan denied your request. The Plan says you have a power wheelchair and Medicare does not cover second wheelchairs.
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 file shows that you have a Group 3 power wheelchair. A power wheelchair serves the same purpose as a manual wheelchair. The item at issue in this appeal is being requested for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan cover wheelchairs for use only outside the home. Medicare only covers one wheelchair at a time. Therefore, we decided that the Plan does not have to pre-approve repairs to your manual wheelchair.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve massage therapy.You asked the Plan to pre-approve these services. You say that the services help with your sciatica condition.The Plan denied your request. The Plan says the services are not covered.The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist.Therefore, we decided that the Plan does not have to pre-approve massage therapy.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve replacement of lower denture to be provide.You asked the Plan to pre-approve the dentures. You say that you are not satisfied with the fit of the dentures you received on July 15, 2019.The Plan denied your request. The Plan says this benefit has been exhausted Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The plan says that replacement of removable and fixed prosthesis is covered once every 5 years. Records show you just received this service on July 15, 2019.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 replacement of lower denture.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea Group 2 very heavy duty power operated vehicle (K0808).You asked the Plan to pre-approvea Golden Tech Avenger 4 wheel scooter. You say that you have had this power scooter in the past and want another.The Plan denied your request. The Plan says the a Golden Tech Avenger 4 wheel scooter has added capabilities that are not needed for use in the home and therefore not covered by Medicare.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 a GoldenTech Avenger 4 wheel scooter have not been met.Therefore, we decided that the Plan does not have to pre-approvea Group 2 very heavy duty power operated vehicle (K0808).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe medical services to be provided by an out of network provider. You asked the Plan to pre-approveoffice consultation. You say that your in-network doctor treats multiple conditions in addition to your condition which makes it difficult to keep up with new drug and treatment protocols, however this provider has a group of doctors who only treat your condition.The Plan denied your request. The Plan says the denial of authorization for this service is correct, because thisprovider is out-of-network with the Plan and you can be treated by an in-network 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 pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services.Therefore, we decided that the Plan does not have to pre-approvethe medical services.