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

We decided that the Plan does not have to pre-approve a 24-inch wide manual wheelchair for the enrollee.
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 there is no valid physician order.
The Plan must follow Medicare rules. The rules say that a physician order is required for durable medical equipment. We looked at the file and Medicare rules. The file shows that there is no valid physician order for the requested manual wheelchair. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a 24-inch wide manual wheelchair for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Otezla tab.You asked the Plan to pre-approve the tab. You say that this is medically necessary.The Plan denied your request. The Plan says this falls under Part D coverage.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 Otezla tab.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveTadalafil tablets.You asked the Plan to pre-approveTadalafil tablets. You say that this medication helps you to walk.The Plan denied your request. The Plan says coverage of this medication is the responsibility of your prescription drug plan.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-approveTadalafil tablets.Benefits for Tadalafil tabletsmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation to be provided in 2019.You asked the Plan to pre-approve additional routine transportation. You say that you need transportation to doctor's appointments.The Plan denied your request. The Plan says the denial of authorization for additional routine transportation is correct, because routine transportation beyond 24 one-way trips per year is 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 a maximum of 24 trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of additional routine transportation.Therefore, we decided that the Plan does not have to pre-approve additional routine transportation to be provided in 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe home infusion services to be provided by an out of network provider..You asked the Plan to pre-approvethe home infusion services. You say that you would like the plan to reconsider their decision.The Plan denied your request. The Plan says the requested services can be provided by a 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.Review of thefile shows that the enrollee may receive services from the provider, just the cost share requirements for the enrollee will be higher.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 to be provided at the in-network rates.Therefore, we decided that the Plan does not have to pre-approvethe home infusion services to be provided at the in network rates.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve breast surgery for the enrollee.You asked the Plan to pre-approve breast surgery. You say that this surgery is medically necessary.The Plan denied your request. The Plan says Medicare coverage criteria were not met.The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are coverable.  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 breast surgery. Our reviewer says that Medicare coverage criteria are not met. Our reviewer found insufficient medical record documentation was submitted to allow coverage of this surgery. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of breast surgery have not been met.Therefore, we decided that the Plan does not have to pre-approve breast surgery for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a kidney transplant evaluation.You asked the Plan to pre-approve the kidney transplant evaluation. You say that you need a kidney to continue in good health and care for your children.The Plan denied your request. The Plan says the information shows that the enrollee has not been following her doctor's orders. The plan says that the information sent shows that the enrollee has not been attending dialysis as prescribed.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 kidney transplant evaluation. Our reviewer says that a kidney transplant evaluation is not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee is a 31-year-old female with a medical history that includes ESRD and hypertension. Our physician reviewer found that a prior evaluation in 2013 for a kidney transplant was aborted because the enrollee was lost to follow up. Our physician reviewer found that the enrollee's BMI is presently 24 and she is a current every day smoker. Our physician reviewer found that the dialysis records list "noncompliance". Our physician reviewer found that approval of a pre-transplant evaluation in this case requires documentation of adequate member compliance with dialysis from the dialysis provider.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 kidney transplant evaluation have not been met.Therefore, we decided that the Plan does not have to pre-approve a kidney transplant evaluation.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ampyra ER 10mg tablet.You asked the Plan to pre-approve the drug. You say that this is medically necessary.The Plan denied your request. The Plan says this is a medical only policy.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 Ampyra ER 10mg tablet.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve anesthesia services (01936).You asked the Plan to pre-approve the anesthesia services. You say that anesthesia is required for comfort and pain reduction. The Plan denied your request. The Plan says the anesthesia 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 anesthesia services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found based on the medical records provided there is no documentation of any increased anxiety or other unstable medical condition with the patient to justify the anesthesia requested.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 anesthesia services have not been met. Therefore, we decided that the Plan does not have to pre-approve anesthesia services (01936).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the complete upper denture and lower partial denture.You asked the Plan to pre-approve the complete upper denture and lower partial denture. You say that the dentures were made 15 years ago and are too old to fit. You say that new ones are needed.The Plan denied your request. The Plan says these are not covered benefits.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approve the complete upper denture and lower partial denture.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that thePlan does not have to pre-approvethe medical services to be provided by out of network provider,"the doctor" You asked the Plan to pre-approvean office visit. You say that you wanted a follow-up appointment with your surgeon.The Plan denied your request. The Plan says the services in question are not medically necessary.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 found thata follow-up appointment is not medicallynecessary. 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 to be provided by out of network provider, "the doctor".
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a FreeStyle Libre continuous glucose monitor system.You asked the Plan to pre-approve a continuous glucose monitor. You say that the enrollee needs a continuous glucose monitor.The Plan denied your request. The Plan says there is no documentation of frequent blood glucose checks and adjustments based on the results.The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered only when they are medically reasonable and necessary and replace a blood glucose monitor.We looked at the file and Medicare rules. The prescription fill record indicates the enrollee is not compliant with treatment recommendations and there is no glucose check records. Based on this information, we decided that Medicare rules for coverage of a continuous glucose monitor have not been met.Therefore, we decided that the Plan does not have to pre-approve a FreeStyle Libre continuous glucose monitor system.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecontinued use of a portable oxygen concentrator.You asked the Plan to pre-approvecontinued use of a portable oxygen concentrator. You say that you are dependent on the portable oxygen concentrator to leave your house or you will become home bound.The Plan denied your request. The Plan says your saturation level does not meet criteria.The Plan must follow Medicare rules. The rules say that to qualify for portable oxygen, the patient must meet the criteria for home oxygen. The documentation must show that the patient is mobile in the home and would benefit from the use of portable oxygenin the home. Portable oxygen is not covered for patients who qualify for oxygen solely based on blood gas studies obtained during sleep.  To qualify for home oxygen, the patient must meet one of the following blood gas levels:1. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, at rest;2. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, taken during sleep for a patient who have hypoxia symptoms during sleep; 
3. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88%, taken during exercise for patients who have hypoxia symptoms during exercise;4. Arterial PO2 between 56 and 59 mmHg and arterial O2 saturation is 89% on room air if there is evidence of dependent edema, pulmonary hypertension, or erythrocythemia.For patients with arterial PO2 at or above 60 mm Hg or arterial O2 saturation at or above 90% on room air, there is a rebuttable presumption of non-coverage.We looked at the file and Medicare rules. You do not meet criteria for a portable oxygen systemor a portable oxygen concentrator. Based on this information, we decided that Medicare rules for coverage of a portable oxygen concentrator have not been met.Therefore, we decided that the Plan does not have to pre-approvecontinued use of a portable oxygen concentrator.
Appeal type: Home Health
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 the referral. You say that you have been with this company for a year, and they have been participating.The Plan denied your request. The Plan says there are participating 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 a referral to Eagle Medical Services, an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe a consult and urinalysis to be provided by an out of network provider.You asked the Plan to pre-approvethe physician services. You say that the enrollee lives in Riverside county, but the medical group is in Orange county. You say that the enrollee's nephrologist is 38 miles away and that is a far drive from dialysis to see a nephrologist. You also say that the enrollee is happy with her primary care physician (PCP) and other specialists and does not want to change groups.The Plan denied your request. The Plan says the services can be provided within your medical group. The Plan also says the services are not urgent or emergent.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plansays 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 networkproviders 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 a consult and urinalysis to be provided by an out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve semi-electric hospital bed with rail and mattress (E0260) to be provided.You asked the Plan to pre-approve semi-electric hospital bed. You say that you are not able to sit in a chair and is always in the bed. You are struggling from extreme pain and has had multiple falls and cannot get out of bed without assistance.The Plan denied your request. The Plan says the enrollee does not meet LCD criteria and is not medically necessary at this time. Bed rails if desired can be attached to a standard bed and does not require a hospital bed.The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered medically necessary when the patient:1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or2. Requires attachments which can only be attached to a hospital bed; AND3. Requires frequent changes in body position and/or has an immediate need for a change in body position.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 semi-electric hospital bed. Our reviewer says that this enrollee does not meet the Medicare criteria. Our physician reviewer found the records do not indicate a need for frequent and/or immediate changes in body position, or need for special attachments that cannot be fixed to an ordinary bed. The necessity for a hospital bed is not substantiated. As such, the request is not medically necessary.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a porcelain crown (D2740) for tooth # 8, a retainer crown (D6751) for teeth # 18 and 20, and a pontic (D6241) for tooth # 19.You asked the Plan to pre-approve the dental services. The Plan denied your request. The Plan says the services you requested are not covered for these teeth.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, bridges are not covered for posterior teeth.Therefore, we decided that the Plan does not have to pre-approve a porcelain crown (D2740) for tooth # 8, a retainer crown (D6751) for teeth # 18 and 20, and a pontic (D6241) for tooth # 19.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the anesthesia to be provided by an out of network provider.You asked the Plan to pre-approve the anesthesia services. You say that anesthesia is required for comfort and pain reduction. You also say that it is necessary for psychological support due to anxiety.The Plan denied your request. The Plan says there are in network providers that can provide the requested services.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 anesthesia to be provided by an out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvetraction equipment.You asked the Plan to pre-approvetraction equipment. You sayyou have tried physical therapy, chiropractic services and medication for your lower back pain and you think that a home decompression machine would help.The Plan denied your request. The Plan says exercise equipment is not covered.The Plan must followMedicarerules. Medicare rules say that services that are not medically necessary are not covered.We looked at the file and Medicare rules. The records do not show that you are unable to ambulate. Based on this information, we decided that Medicare rules for coverage of traction equipment have not been met.Therefore, we decided that the Plan does not have to pre-approvetraction equipment.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea bike helmet.You asked the Plan to pre-approvea bike helmet. You say that you have a history of chronic back pain and the only way to get daily physical activity is through bicycling and your current bike helmet is in disrepair.The Plan denied your request. The Plan says the criteria is not met and you do not have a covered condition that qualifies the helmet for DME use.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 bike helmet.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a surgical placement of implant body: endosteal implant to be provided. You asked the Plan to pre-approve the endosteal implant. You say that you need dental implants for 2 molars. You also say that you saw a television advertisement that states that implants are covered when they are necessary.The Plan denied your request. The Plan says this service is not a covered benefit. The Plan also says the advertisement that you saw is for the 2020 benefit year.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 surgical placement of implant body: endosteal implant to be provided.