Persius/hicric huggingface dataset:
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xgeva.

You asked the Plan to pre-approve Xgeva. You say that the requested Xgeva is medically necessary. The Plan denied your request. The Plan says the enrollee must try and fail Zoledronic Acid first.

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 Xgeva. Our reviewer says that the Plan's step therapy criteria have not been met. Our physician reviewer found the Plan requires a trial of Zoledronic Acid first before they will approve the requested drug. In this case, the enrollee has not tried and failed the required drug(s). There is no documentation provided indicating that the plan's required drug(s) 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 Xgeva have not been met. Therefore, we decided that the Plan does not have to pre-approve Xgeva.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet injections.

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 medically necessary.

The Plan must follow Medicare rules. Medicare rules say that facet injections are covered when specific criteria
are met.

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 records show that you have chronic
low back pain. You have had fractures of the lumbar spine at the L2 and L5 discs. You last had physical
therapy in 2017. The records show you have multiple alternative possible sources for the pain and have not had
recent conservative therapy. The criteria for coverage of facet injections are not met and the services are 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-approve facet injections.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve implant maintenance procedures when prostheses are
removed and reinserted (D6080).

You asked the Plan to pre-approve the implant maintenance procedures. The Plan denied your request. The
Plan says this service is 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
implant maintenance procedures when prostheses are removed and reinserted (D6080).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a maxillary partial denture (D5225) and a mandibular partial denture (D5226).

You asked the Plan to pre-approve the maxillary partial denture and mandibular partial denture. You say that you would like these dentures to be approved for coverage. The Plan denied your request. The Plan says these services are not covered.

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 maxillary partial denture (D5225) and a mandibular partial denture (D5226).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex Superion device (22869, 22870).

You asked the Plan to pre-approve the Vertiflex Superion device. You say that due to this enrollee's age and
condition you feel the following treatment would be the safest and most effective course of action. The Plan
denied your request. The Plan says Vertiflex is experimental and investigational. There are not enough studies
to show that it is safe and effective. The enrollee is not receiving this device as part of a Medicare covered
clinical trial.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered. The rules also say that experimental and investigational devices are not covered.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the Vertiflex Superion device have not been met. Therefore, we decided that the Plan does not
have to pre-approve the Vertiflex Superion device (22869, 22870).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable ventilator to be provided by the out-of-network
provider.

You asked the Plan to pre-approve the portable ventilator to be provided by the out-of-network provider. The
Plan denied your request. The Plan says you must receive care from in-network providers with the exception of
emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be
provided with an in-network provider, which requires prior authorization from the plan.

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 item at issue in this appeal. We found no exception that would require the Plan
to pre-approve this item. Therefore, we decided that the Plan does not have to pre-approve a portable ventilator
to be provided by the out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Osseous surgery (D4261), bone replacement graft
(D4264), guided tissue regeneration (D4266), and local anesthesia (D9215).

You asked the Plan to pre-approve Osseous surgery, bone replacement graft, guided tissue regeneration, and
local anesthesia. You say that these services are medically necessary. The Plan denied your request. The Plan
says these services are not covered under your supplemental 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
Osseous surgery (D4261), bone replacement graft (D4264), guided tissue regeneration (D4266), and local
anesthesia (D9215).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a dental crown and core buildup for tooth #31.

You asked the Plan to pre-approve the requested services. You say that you have no funds to finish the procedure. The Plan denied your request. The Plan says you are responsible for any amount over the allowed amount.

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, and Medicare rules. The file shows the services are covered up to the dental benefit allowed amount. Once you have reached the $1500 allowed amount for supplemental dental services, you will have exhausted the Plan's the Plan maximum benefit for covered dental services. You will be responsible for any amount over the allowance amount. Therefore, we decided that the Plan does not have to pre-approve a dental crown and core buildup for tooth #31 beyond the allowance amount.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve upper eyelid blepharoplasty.

You asked the Plan to pre-approve upper eyelid blepharoplasty. You say that the requested upper eyelid blepharoplasty is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested upper eyelid blepharoplasty.

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 upper eyelid blepharoplasty. Our reviewer says that the enrollee does not meet criteria for the requested upper eyelid blepharoplasty. Our physician reviewer found Medicare criteria were not met for upper eyelid blepharoplasty based on the lack of superior visual field loss upon visual field testing, and a lack of demonstrated improvement with eyelid elevation. The visual field tests provided in the record did not meet the requirement of "12 degree or 30 percent loss" in superior field that improved with elevated or taped eyelids. Criteria have not been met.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of upper eyelid blepharoplasty have not been met. Therefore, we decided that the Plan does not have to pre-approve upper eyelid blepharoplasty.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the abdomen and pelvis (74176).

You asked the Plan to pre-approve a CT scan. You say that this is medically necessary. The Plan denied your request. The Plan says this is not indicated.

The Plan must follow Medicare rules. Medicare rules say that CT 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 a CT scan. Our reviewer says that the requested CT scan is not shown to be medically necessary. Our physician reviewer found the legible portions of the submitted documentation do not provide support for the requested test. The assessment noted does not indicate a diagnosis for which a CT scan of the abdomen and pelvis would be medically reasonable or necessary. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the abdomen and pelvis (74176).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Tandem Insulin pump.

You asked the Plan to pre-approve a Tandem Insulin pump. You say that you would like reconsideration because the warranty for your current insulin pump is up and you would like a Tandem Insulin pump because it is lighter weight. The Plan denied your request. The Plan says your current pump is functioning normally, is still in warranty and your glucose control is at near goal.

The Plan must follow Medicare rules. Medicare rules say that in no case can the reasonable useful lifetime of durable medical equipment be less than 5 years. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a Tandem Insulin pump have not been met. Specifically, the record indicates that your current pump is functioning and not in need of replacement or repair. Therefore, we decided that the Plan does not have to pre-approve a Tandem Insulin pump.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve PET/CT scan of the head and brain.

You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your request. The Plan says there is no indication of progressive decline.

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/CT of the head is only covered for the evaluation of dementia in those patients who: "with a recent diagnosis of dementia and documented cognitive decline of at least 6 months, who meet diagnostic criteria for both AD and FTD." The notes provided indicate that you have mild cognitive impairment. However, you are not noted to meet diagnostic criteria for either AD or FTD let alone both diagnoses. Consequently, it cannot be said that the requested study would be performed in accordance to the standards set forth by the Medicare guidelines.

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 PET/CT scan of the head and brain.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two crowns.

You asked the Plan to pre-approve the crowns. You say that you would like these services to be covered. The Plan denied your request. The Plan says this service is not a covered benefit 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 two crowns.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide routine transportation (A0170) with a limit of 80 miles per one-way trip.

You asked the Plan to provide 80-mile one-way transportation. You say that you were not told that routine transportation now has mileage limitations, and you do not want to have to find new doctors due to these distance restrictions. The Plan denied your request. The Plan says the routine transportation is a covered benefit, but a one-way trip that exceeds 75 miles is beyond the limits set in the Plan's annual contract. Trips that are greater than 75 miles are not covered by the Plan.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers routine transportation for up to 60 one-way trips with a maximum distance of 75 miles per trip. 

We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to provide routine transportation (A0170) with a limit of 80 miles per one-way trip.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two pontics (D6245 x2) and three retainer crowns (D6740 x3).

You asked the Plan to pre-approve the pontics and retainer crowns. You say that you would like these services to be approved for coverage for the enrollee. The Plan denied your request. The Plan says these services are not covered.

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 two pontics (D6245 x2) and three retainer crowns (D6740 x3).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that the enrollee needs inpatient rehab services. The Plan denied your request. The Plan says IRF services are not medically necessary.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core build up (D2950) and a crown (D2750) for tooth #
18.

You asked the Plan to pre-approve the dental services. You say that you had a crown placed.
You say that you went back to the dentist because the crown broke. You say that the crown
had to be replaced instead of repaired. You say that temporary crowns are not reliable. You say that you have
had 3 replaced. You also say that you need the crown as soon as possible as it is sometimes challenging to eat.
The Plan denied your request. The Plan says crowns and core build up are covered once every 5 plan years.
The Plan says that the frequency limits have been exceeded.

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 services are listed as covered,
the frequency limits have been reached. The record shows that the Plan paid for a crown and core build up for
tooth # 18. Therefore, we decided that the Plan does not have to pre-approve core build up (D2950) and a crown
(D2750) for tooth # 18.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a porcelain crown (D2740) for tooth # 23.

You asked the Plan to pre-approve the dental service. You say that the enrollee needs a crown for tooth # 23.
The Plan denied your request. The Plan says porcelain crown 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 a
porcelain crown (D2740) for tooth # 23.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the back-up portable oxygen car charger.

You asked the Plan to pre-approve the back-up portable oxygen charger. You say that you would like reconsideration because your portable oxygen equipment only holds charge for two hours. The Plan denied your request. The Plan says Medicare does not cover backup chargers.

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 charger, an AC power adapter and a DC power adapter. The requested back up charger portable oxygen tanks and supplies serves the same purpose as the chargers that were provided with your portable oxygen equipment. Therefore, we decided that the Plan does not have to pre-approve the back-up portable oxygen car charger.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia.

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 medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has metastatic prostate cancer and is on androgen deprivation therapy. The use of Prolia requires that the enrollee be at high risk for fracture and receiving androgen deprivation therapy for non-metastatic prostate cancer. The enrollee does not have osteporosis or osteopenia. The services are therefore not considered safe and effective and reasonable and medically necessary 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia.