Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the implantation of a cranial nerve (hypoglossal) stimulator (64568 and 0466T). You asked the Plan to pre-approve the implantation of a cranial nerve stimulator. You say that you need this treatment is medically necessary.The Plan denied your request. The Plan says this treatment is not covered by Medicare or the Plan.The Plan must follow Medicare rules. Medicare rules say that ranial nerve (hypoglossal) stimulation for the treatment of obstructive sleep has been determined to be not reasonable and necessary.We looked at the file and Medicare rules. The requested services are not considered reasonable and necessary under Medicare. Based on this information, we decided that Medicare rules for coverage of the implantation of a cranial nerve stimulator have not been met.Therefore, we decided that the Plan does not have to pre-approve the implantation of a cranial nerve (hypoglossal) stimulator (64568 and 0466T).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea sit to stand frame/table system to be provided by "the provider".You asked the Plan to pre-approvea sit to stand frame/table system. You say that the enrollee would benefit froma standing frame to assist in pressure relief, pain relief, and improved range of motion.The Plan denied your request. The Plan says a standing table is a convenience item and not primarily medical in nature.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 sit to stand frame/table system to be provided by "the provider".
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a stem cell transplant.
You asked the Plan to pre-approve these services. You say that the services should be covered. The Plan denied your request. The Plan says the services are not covered for your condition.
The Plan must follow Medicare rules. The rules say that stem cell transplants are covered for specific indications only. We looked at the file and Medicare rules. The file shows that you are requesting a stem cell transplant for bilateral knee pain. This is not a condition for which stem cell transplants are covered. Therefore, we decided that the Plan does not have to pre-approve a stem cell transplant.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea computed tomography (CT) scan to evaluate coronary calcium (75571).You asked the Plan to pre-approvea CT scan to evaluate coronary calcium. You say that this is medically necessary.The Plan denied your request. The Plan says this service is not covered by Medicare.The Plan must follow Medicare rules. Medicare rules say that quantitative calcium scoring is not a covered service and will be denied as not medically necessary. We looked at the file and Medicare rules. The service at issue is calcium scoring. Based on this information, we decided that Medicare rules for coverage of a CT scan to evaluate coronary calcium have not been met.Therefore, we decided that the Plan does not have to pre-approvea computed tomography (CT) scan to evaluate coronary calcium (75571).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core buildup tooth #30 (D2950) and crown tooth #30 (D2750) provided by the doctor.
You asked the Plan to pre-approve the dental services. You say that you need a deep cleaning because you are in pain due to a tooth. You need a tooth extraction and a crown. The Plan denied your request. The Plan says these services are not covered under the plan 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 core buildup tooth #30 (D2950) and crown tooth #30 (D2750) provided by the doctor.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve removal of extra bone in roof of mouth lower left quadrant (D7473) lower right quadrant (D7473) deep sedation first 15 minutes (D9222x2) and deep sedation each 15 minutes (D9223).You asked the Plan to pre-approve the dental services. You say that you have to have 11 teeth pulled which is why you need general anesthesia. You have been approved the extractions but you need help.The Plan denied your request. The Plan says the services are not covered benefits under the 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 removal of extra bone in roof of mouth lower left quadrant (D7473) lower right quadrant (D7473) deep sedation first 15 minutes (D9222x2) and deep sedation each 15 minutes (D9223).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the first 15 minutes of deep sedation/general anesthesia, 2 subsequent 15 minute increments of deep sedation/general anesthesia, and single administration of therapeutic parenteral drug.
You asked the Plan to pre-approve the deep sedation/general anesthesia services and therapeutic drug administration. You say that the enrollee would not be able to tolerate the removal of tooth #14 that is abscessed and non-restorable. You also say that the best course of action would be to remove these teeth with deep intravenous sedation. The Plan denied your request. The Plan says these services are not covered under the enrollee's contract under any normal circumstances.
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 the first 15 minutes of deep sedation/general anesthesia, 2 subsequent 15 minute increments of deep sedation/general anesthesia, and single administration of therapeutic parenteral drug.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to providea power mobility device.You asked thePlan to providea power mobility device. You say that the enrollee needs a scooter in-home and out of home due to gait impairment, leg weakness, and imbalance from a medical condition.The Plan denied your request. The Plan says there is no detailedwritten order, specialty evaluation, or home evaluation documentation.The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating therequested PMD. The file does not showthat you have a mobility deficit that impairs your participation in MRADLs, your condition cannot be improved by a walker, cane or manual wheelchair, or you can safely operate the PMD being requested. There is no home evaluation documentation. This means that Medicare rules for coverage of a PMD have not been met.Therefore, we decided that the Plan does not have to providea power mobility device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve upper and lower false teeth and bone adjustment.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 upper and lower false teeth and bone adjustment.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvebag hooks for a wheelchair.You asked the Planto pre-approvethe accessories. You say that this is medically necessary.The Plandenied your request. The Plansaysthis is not a covered benefit.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 Plandoes not haveto pre-approvebag hooks for a wheelchair.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Diclofenac Sodium gel.You asked the Plan to pre-approve Diclofenac Sodium gel. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested drug is not a covered benefit.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 Diclofenac Sodium gel.Benefits for Diclofenac Sodium gel 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve removal of knee cartilage for the enrollee.
You asked the Plan to pre-approve the removal. You say that this is medically necessary. The Plan denied your request. The Plan says there is no documented functional limiting pain, impaired range of motion such as a blocked knee, weakness or evidence of conservative treatment.
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 removal. Our reviewer says that the requested procedure is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee presented on 11/4/19 with acute onset of left knee pain following a fall on 11/1/19. X-rays were reported negative for fracture. Initial clinical exam documented exquisite medial joint line pain and limited range of motion. The diagnosis was documented as left knee medial collateral ligament sprain, internal derangement. He has failed to improve with conservative treatment, including activity modification, physical therapy and medications. Authorization was requested for left knee meniscectomy, medial and/or lateral with chondroplasty. Current evidence based medical literature supports meniscectomy for patients with symptomatic meniscal tears who have failed conservative treatment, have mild or no osteoarthritis, and have positive meniscal clinical exam findings. In this case, the medical records are limited and do not document current subjective complaints, including mechanical symptoms, or functional limitations. No meniscal provocative testing is documented. Additionally, there are no imaging reports submitted for review and no imaging findings, including potential osteoarthritis, discussed in the medical records. Given the limited medical records, the medical necessity of this request cannot be established. Therefore, this request for knee surgery (CPT codes 29880 and 29881) is not reasonable and 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 the removal have not been met. Therefore, we decided that the Plan does not have to pre-approve removal of knee cartilage for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveDiazepam 2mg Tablets.You asked the Plan to pre-approveDiazepam. You say that the diazepam is medically necessary.The Plan denied your request. The Plan says coverage for Diazepam tablets is not available under the Part B medical benefit.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-approveDiazepam 2mg Tablets.Benefits for Diazepammay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental implants.You asked the Plan to pre-approve these services. You say that your jaw has healed from previous procedures and you now need dental implants.The Plan denied your request. The Plan says the services are not covered.Medicare generally does not cover dental services. The Plan follows the same rule.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 dental implants.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by out of network provider.You asked the Plan to pre-approve ophthalmology services. You say that this is the only doctor you trust with your diagnoses. You say that you would like to continue seeing the doctor.The Plan denied your request. The Plan says no follow-up appointments are necessary. The Plan says that there are in-network providers available.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-approve the medical services to be provided by out of network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveOmeprazole capsules.You asked the Plan to pre-approveself-administered drugs. You say that you are appealing.The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because this drug is not covered by Medicare Part B and the Plan does not administer your Medicare Part D prescription drug benefits.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-approveOmeprazole capsules.Benefits for self-administered drugsmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approvediclofenac 3% gel.You asked the Plan to pre-approvethese services. You say that the enrollee has been using the drug for pain management.The Plan denied your request. The Plan says self-administered drugs are not a covered benefit.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-approvediclofenac 3% gel.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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve replacement hearing aid batteries.
You asked the Plan to pre-approve the replacement hearing aid batteries. You say that have no money and needs the assistance. The Plan denied your request. The Plan says hearing aid batteries are supplied with the initial hearing aid only. Replacement hearing aid batteries are not a covered benefit.
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. We looked at the file, and the Plan's rules. The Plan hearing aid benefit covers batteries supplied with the initial hearing aid only. Replacement hearing aid batteries are not a covered benefit. Therefore, we decided that the Plan does not have to pre-approve replacement hearing aid batteries.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician's services to be provided. You asked the Plan to pre-approve the physician's services. You say that you would like to see the provider for glaucoma because he treated you in the past with eye drops and your vision has improved. The Plan denied your request. The Plan says your plan requires you to receive care from providers who are part of your primary care physician's (PCP) and/or Medical Group network.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 pre-approved care.The contract with the Plan also says that your plan requires you to receive care from providers who are part of your PCP and/or Medical Group network.The requested provider in this case is not part of your PCP and/or Medical Group network.The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve the requested services. Therefore, we decided that the Plan does not have to pre-approve physician's services to be provided
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve suturing of tantalum rings (67299) with an out-of-network
provider.
You asked the Plan to pre-approve suturing of tantalum rings (67299) with an out-of-network provider. You
say that the requested suturing of tantalum rings is medically necessary. The Plan denied your request. The
Plan says that the requested suturing of tantalum rings is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item
or service, then that item or service will be covered when it is medically necessary.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve suturing of tantalum rings (67299). Our
reviewer says that the requested suturing of tantalum rings is medically necessary. Our physician reviewer
found the enrollee is with choroidal melanoma. The plan approved aspiration of orbital contents, aspiration
biopsy, and aspiration of vitreous, subretinal or choroidal fluid (67015, 10021, and 67415). The plan approved
proton beam radiation therapy.
The insertion/suturing of ocular tantalum markers (ring) is medically necessary to allow for targeting of the
proton therapy. As a radiation oncologist, this treatment is well within the accepted standards of care and would
meet all of the medical necessity criteria as a result.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of suturing of tantalum rings (67299) have been met. Therefore, we decided that
the Plan has to pre-approve suturing of tantalum rings (67299) with an out-of-network provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
You asked the Plan to pre-approve admission to a skilled nursing facility (SNF). You say that the requested admission to a SNF is medically necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet criteria.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 admission to a skilled nursing facility (SNF). Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to acute care with recurrent meningioma admitted for cranioplasty and discharged back to the SNF. He had a history of tracheostomy and feeding tube placed in the past. From a nursing perspective, the enrollee received enteral feeds and medications and insulin. The enrollee had stable vital signs. He had routine tracheostomy care. His lungs were clear. Regarding rehabilitation services, the enrollee received physical therapy, speech therapy and occupational therapy in the SNF. The enrollee was dependent for care and functional mobility. He required a mechanical lift for transfers. There are identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. This enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 admission to a skilled nursing facility (SNF) have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.