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

We decided that the Plan does not have to pre-approve interdry dressings.

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. The rules say that skin sealants or barriers (A6250) are not covered. 

We looked at the file and Medicare rules. The requested services are dressings described by code A6250. These services are not covered by Medicare. Therefore, we decided that the Plan does not have to pre-approve interdry dressings.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 8 additional non-cuffed tracheostomy tubes.

You asked the Plan to pre-approve the requested items. The Plan denied your request. The Plan says the documentation does not show that the additional supplies are medically necessary.

The Plan follows Medicare rules. Medicare rules say that tracheostomy supplies are only covered under certain medical indications. 

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 requested items. Our physician reviewer found that you are post laryngectomy. In this case, the requested number of tubes exceeds the number allowed under the rules. The provided documentation does not establish that the additional tubes are 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 the requested items have not been met. Therefore, we decided that the Plan does not have to pre-approve 8 additional non-cuffed tracheostomy tubes.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc (J7325).
You asked the Plan to pre-approve Synvisc (J7325). You say that you want the enrollee treated with this drug. The Plan denied your request. The Plan says the health plan states the enrollee has not first tried and had a contraindication or intolerance to Orthovisc.
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 (J7325). Our reviewer says that the drug is not reasonable and medically necessary. Our physician reviewer found based on the medical records provided the patient has not tried and failed the required drug. There is no indication that the plan's required drug would likely be less effective and/or likely have adverse effects for the patient. 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 (J7325) have not been met. Therefore, we decided that the Plan does not have to pre-approve Synvisc (J7325).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve mandibular partial denture - cast metal framework with resin denture bases (D5214) and maxillary partial denture - cast metal framework with resin denture bases (D5213).
You asked the Plan to pre-approve the upper and lower partial dentures. You say that the services are necessary. The Plan denied your request. The Plan says this service is covered under the member's benefit package, but exceeds the maximum count allowed per period.
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 dentures when the services are provided once every five years. We looked at the file and Medicare rules. The Plan provided documentation showing that upper and lower partial dentures have been covered by the Plan in the past five years. Based on this information, we decided that the Plan's rules for coverage of the dentures have not been met. Therefore, we decided that the Plan does not have to pre-approve mandibular partial denture - cast metal framework with resin denture bases (D5214) and maxillary partial denture - cast metal framework with resin denture bases (D5213).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee meets the Medicare criteria for LTACH admission. The Plan denied your request. The Plan says the denial of authorization for LTACH service is correct.
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. Our physician reviewer found the enrollee is receiving appropriate care at the present acute care hospital. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the Plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee 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 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.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital services.
You asked the Plan to pay for inpatient hospital services. You say that these services are medically necessary.
The Plan denied your request. The Plan says that all the care that you received could be provided in an
observation level of care.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases,
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or
more.
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 inpatient hospital services. Our reviewer
says that inpatient hospital services are not medically reasonable and necessary. You were admitted to the
hospital with increased drainage from a surgical incision. Wound vac was needed, and your outpatient provider
recommended you get this via the emergency department. Workup did not show evidence of infection or other
acute condition to justify inpatient services. Lower level of care would have been more appropriate considering
your stability and low complexity of your needs. Our physician reviewer found that your condition does not
meet Medicare criteria for inpatient hospital 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 inpatient hospital services have not been met. Therefore, we decided that the
Plan does not have to pay for inpatient hospital services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of Yervoy.
You asked the Plan to pre-approve Yervoy. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because the requested use of Yervoy is not Food & Drug Administration approved or supported by drug compendia.
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 Yervoy. Our reviewer says that the enrollee does not meet the Medicare criteria for Yervoy. Our physician reviewer found this is not first-line therapy and the enrollee has progressed on Keytruda, another checkpoint inhibiter. The requested use of Yervoy is not Food & Drug Administration (FDA) approved for the enrollee's diagnosis. This use of Yervoy is not supported by one of the major drug compendia or by research that appears in a Medicare-approved medical journal. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Yervoy have not been met. Therefore, we decided that the Plan does not have to pre-approve use of Yervoy.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the enrollee needs constant supervision and would have no medical care with her at home. The Plan denied your request. The Plan says that the denial of authorization for continued SNF care after April 29, 2021 is correct.
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 care. Our reviewer says that the enrollee meets the Medicare criteria for continued SNF care after April 29, 2021. Our physician reviewer found the enrollee has daily skilled nursing needs that require the specialized skill, knowledge, and judgement of a skilled professional nurse. The enrollee does not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. Daily skilled services are required to establish a maintenance program and/or to prevent deterioration of the enrollee's condition. The enrollee requires daily skilled nursing and/or skilled therapy on an inpatient basis in a Skilled Nursing Facility (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 care have been met. The Plan must continue coverage for the SNF skilled service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing facility (SNF) care.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the hand x-ray rendered on August 26, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the claim is a duplicate.
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied. We looked at the file and Medicare rules. The file shows that the services at issue were previously paid by the Plan on a separate claim for the same date of service. 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 pay for the hand x-ray rendered on August 26, 2020.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve the crowns - porcelain/ceramic for teeth # 6 and 11 (D2740).
You asked the Plan to pre-approve the crowns. You say that a prior dentist built the enrollee up with pins and have fractured off and require full coverage crowns. The Plan denied your request. The Plan says that the teeth do not appear to have significant breakdown and therefore criteria for coverage are not met.
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 crowns when the teeth have significant breakdown. 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 crowns. Our reviewer says that due to the large restorations present in the teeth (#6 and 11) they are subject to fracture. Crown restorations would provide the necessary support for good function. The criteria for coverage for crowns have been met. 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 crowns have been met. Therefore, we decided that the Plan has to pre-approve the crowns - porcelain/ceramic for teeth # 6 and 11 (D2740).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a step stool (E1399).

You asked the Plan to pre-approve a step stool. You say that you received 2 knee braces that are too heavy. You were advised the knee braces that you would get used to the knee brace but you never did. The Plan denied your request. The Plan says this item is not medical in nature and is regularly and primarily used by person's who do not have a specific medical need for them.

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 step stool (E1399).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous positive airway pressure (CPAP) device
and related supplies to be provided by an OON provider.
You asked the Plan to pre-approve OON services. The Plan denied your request. The Plan says there are
providers available in-network.
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 file shows that a CPAP device, humidifier, tubing, and filters were requested. 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 at issue in this appeal. We found no exception that would require the Plan to pre-approve these OON
services. Therefore, we decided that the Plan does not have to pre-approve a continuous positive airway
pressure (CPAP) device and related supplies to be provided by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the neuromuscular stimulator and supplies rendered on July
30, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says there is no valid physician order.
The Plan must follow Medicare rules. The rules say that a supplier must have an order from the treating
physician before dispensing any DMEPOS item to a beneficiary.
We looked at the file and Medicare rules. There is no valid physician order for the DME. 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 pay for the neuromuscular stimulator and supplies rendered on July 30,
2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a total electric hospital bed.
You asked the Plan to pre-approve total electric hospital bed. You say that this item is necessary for the
enrollee. The Plan denied your request. The Plan says the denial of authorization for this device is correct,
because total electric hospital beds are not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that total electric hospital beds are not covered by
Medicare.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of total electric hospital bed have not been met. Therefore, we decided that the Plan does not have to
pre-approve a total electric hospital bed.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for golf club fees for a players club pass from
January 5, 2021, through February 5, 2021
You asked the Plan to reimburse you for the golf club fees for a players club pass. The Plan denied your request. The Plan says Players Club is not covered by the Plan.
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan's rules for coverage of gym benefits have not been met because players club is not a covered fitness benefit under your Plan. Therefore, we decided that the Plan does not have to reimburse you for golf club fees for a players club pass from January 5, 2021, through February 5, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a PET/CT scan for the enrollee.
You asked the Plan to pre-approve the scan. You say that this is needed for further evaluation of the enrollee's
high risk prostate cancer for metastases. The Plan denied your request. The Plan says this is not medically
necessary.
The Plan must follow Medicare rules. Medicare rules say that PET scans 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 scan. Our reviewer says that the
requested scan is not medically reasonable or necessary. Our physician reviewer found PET scans are not
indicated for the initial staging of prostate cancer. NCCN Guidelines recommend only if bone scan is
equivocal. The enrollee has not yet had any staging imaging.
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 scan have not been met. Therefore, we decided that the Plan does not have
to pre-approve a PET/CT scan for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the retainer crown (D6740) for tooth # 6 provided on November 30, 2020.
You asked the Plan to pay for the dental service. You say that you broke a tooth while eating. You say that by the time you were able to get in to see a dentist, the tooth had deteriorated enough where it could not be saved. You say that without this procedure, your chewing and eating would be hindered. You say that this was not an elective procedure. You also say that you have dental insurance and do not understand why this is being denied. The Plan denied your request. The Plan says there is an annual maximum benefit of $1,000 per year for covered dental services. The Plan says that the maximum benefit has been exhausted. The Plan also says after the annual maximum is exhausted, any remaining charges are your responsibility.
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 and the service is listed as covered, the annual maximum benefit has been exhausted.
The Evidence of Coverage clearly states that after the annual maximum is exhausted, any remaining charges are your responsibility. Therefore, we decided that the Plan does not have to pay for the retainer crown (D6740) for tooth # 6 provided on November 30, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve balloon dilation for the enrollee.
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied your request. The Plan says this 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 the procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation stating the enrollee has symptoms related to the sinus disease such as nasal obstruction, nasal drainage, facial pain/pressure, loss of smell, etc. There is no documentation of failed medical management for chronic sinusitis including saline rinses, antihistamines, or steroid nasal spray. 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 procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve balloon dilation for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Tempur-pedic mattress and base.

You asked the Plan to pre-approve these services. You say that you have had three spinal surgeries. The Plan denied your request. The Plan says the services are not covered.

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 Tempur-pedic mattress and base.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network provider.

You asked the Plan to pre-approve these services. You say that you do not wish to change providers. The Plan denied your request. The Plan says the services are available from network providers.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and 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 a referral to an out-of-network provider.