Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the core build up (D2950) and pulp cap (D3120).

You asked the Plan to pay for the dental services. You say that you feel that your insurance could cover some of this bill based on the literature that you have. You also say that your insurance covers up to $1,000 for dental services. The Plan denied your request. The Plan says core build up is not listed as a covered service. The Plan says that pulp cap is not listed as a covered service either.

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 pay for the core build up (D2950) and pulp cap (D3120).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Opdivo (nivolumab) treatments with Erbitux.

You asked the Plan to pre-approve the Opdivo. You say that there is support for this regimen in the literature. The Plan denied your request. The Plan says there is no support of use of another in the same drug class which recently led to progression of disease.

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 the Opdivo. Our reviewer says that the requested use of Opdivo is not medically reasonable and necessary. Our physician reviewer found the enrollee has metastatic squamous cell carcinoma of the head/neck. There was progression after a recent cycle of pembrolizumab, a programmed death-ligand one (PD-L1) inhibitor. The use of another PD-L1 inhibitor, such as Opdivo, is not supported as likely to be effective after the failure of another of this drug class. There is also no compendia support for the combination of Opdivo with Erbitux. 

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 Opdivo have not been met. Therefore, we decided that the Plan does not have to pre-approve Opdivo (nivolumab) treatments with Erbitux.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung cancer screening.

You asked the Plan to pre-approve the requested LDCT scan. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of a LDCT scan.

The Plan must follow Medicare rules. The rules say that Medicare covers one annual LDCT scan for lung cancer screening for enrollees who meet all the above described criteria. 

We reviewed the file and the Medicare rules. We find that the enrollee does not meet criteria for coverage of a LDCT scan. Specifically, the enrollee's smoking history is documented as 17 pack years, which is less than the requirement of 30 pack years. Additionally, recent lung cancer screenings documented multiple small pulmonary nodules. Therefore, we decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung cancer screening.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete series of radiographic images (D0210), panoramic radiographic images (D0330) and unspecified preventive service (D1999).

You asked the Plan to pay for the dental services. You say that you would like reconsideration because you went to an in-network provider and only wanted to receive the preventive dental services including cleaning. The Plan denied your request. The Plan says these services are 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 pay for the complete series of radiographic images (D0210), panoramic radiographic images (D0330) and unspecified preventive service (D1999).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.

You asked the Plan to pre-approve foot orthotics. You say that without properly fitted foot orthotics, walking is very difficult and painful. The Plan denied your request. The Plan says this item is not a covered benefit.

Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. 

Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Orencia (J0129).

You asked the Plan to pre-approve Orencia. You say that this should be covered. 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-approve Orencia (J0129).

Benefits for Orencia 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a transcutaneous electrical nerve stimulation (TENS) device (E0730) to be rendered by the out of network (OON) provider.

You asked the Plan to pre-approve this item. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says you must receive your care from a network provider. In most cases, care you receive from an out of network provider will not be covered. Additionally, you have been authorized to receive a TENS device from a Plan participating 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 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 transcutaneous electrical nerve stimulation (TENS) device (E0730) to be rendered by the out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Ofev 150mg capsule medication.

You asked the Plan to pre-approve this medication. You say that this medication is medically necessary for the enrollee. The Plan denied your request. The Plan says this medication is not a covered benefit under the enrollee's contractual 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 drug requested here is not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve the Ofev 150mg capsule medication.

Benefits for this medication 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 placement of the Superion interspinous spacer.

You asked the Plan to pre-approve the Superion procedure. You say that this is an effective treatment and should be allowed for this enrollee. The Plan denied your request. The Plan says there is not sufficient data to support this device's usefulness for the enrollee's condition.

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 Superion procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this 82-year-old male was being treated for spinal stenosis, lumbar region with neurogenic claudication. However, current evidence-based medical guidelines and peer-reviewed literature do not fully support the spinal decompression device procedure over the standard of lumbar laminectomy. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of this device for this enrollee's medical condition.

Food and Drug Administration (FDA) indications include implantation of the Superion device at one or two adjacent lumbar levels in patients with moderate spinal stenosis in whom operative treatment is indicated at no more than two levels, from L1 to L5. This enrollee has multiple degrees of spinal stenosis, many not at FDA-indicated levels of "moderate" spinal stenosis. FDA contraindications include spinal instability, scoliosis, obesity, and osteoporosis, and have not been adequately addressed in the medical records. There is a history of scoliosis (noted as "mild"); however, there is no documentation of the Cobb angle. There is no discussion indicating that a bone density scan has demonstrated no significant osteoporosis in this patient. Overall, the requested Superion spacer is not medically reasonable or necessary for this enrollee.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Superion procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve placement of the Superion interspinous spacer.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental implant services (D7953, D6010, D6058,
D6057).

You asked the Plan to pre-approve the dental implant services. You say that these services are medically
necessary. The Plan denied your request. The Plan says these services are not covered by Medicare or the
Plan's supplemental dental 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
dental implant services (D7953, D6010, D6058, D6057).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an extraction of an erupted tooth (D7210).

You asked the Plan to pre-approve an extraction. You say that you would like to use an out of network provider for this service. The Plan denied your request. The Plan says supplemental dental services must be received from a participating provider in order to be covered by 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. 

We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of an extraction have not been met. Specifically, the request is for services to be provided out of network. The Plan has network providers available to provide the services at issue. We found no exception that would require the Plan to pre-approve out of network services. Therefore, we decided that the Plan does not have to pre-approve an extraction of an erupted tooth (D7210).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the sacroiliac (SI) joint nerves.

You asked the Plan to pre-approve the SI RFA procedure. You say that you believe that this is needed to help reduce your pain. The Plan denied your request. The Plan says this type of procedure is not shown to be medically reasonable and 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 SI RFA procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has low back pain with a remote history of spinal surgery and drainage of a spinal infection. He has had Epidural steroid injection, Physical Therapy, and takes Ibuprofen for pain. He has had bilateral SI joint injections which provided him with 10 days of 100% pain relief. RFA of these nerves is now requested. 

RFA of the SI joint nerves is considered an experimental/investigational procedure because of the wide variation in efficacy reported in the peer-reviewed literature. Therefore, the request is considered not 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 the SI RFA procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the sacroiliac (SI) joint nerves.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a provisional crown (D2799) for tooth # 21.

You asked the Plan to pre-approve the dental service. You say that this service should be approved. You also
say that another tooth was approved with no problems. The Plan denied your request. The Plan says provisional
crown is not listed as a covered service. The Plan also says that any services not listed 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. The Evidence of Coverage clearly states that any services not listed are
not covered. Therefore, we decided that the Plan does not have to pre-approve a provisional crown (D2799) for
tooth # 21.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Computed Tomography (CT) colonography.

You asked the Plan to pre-approve CT colonography. You say that you are appealing with records. The Plan
denied your request. The Plan says the denial of authorization for this test is correct, because screening CT
colonography is non-covered.

The Plan must follow Medicare rules. Medicare rules say that screening CT colonography is non-covered.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of CT colonography have not been met. Therefore, we decided that the Plan does not have to pre-approve
Computed Tomography (CT) colonography.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve a dental crown (D2752) on tooth # 19.

You asked the Plan to pre-approve a dental crown. You say that the requested dental crown is necessary. The Plan denied your request. The Plan says that the requested dental crown is not necessary.

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 a dental crown when the services are medically necessary and reasonable.

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 dental crown. Our reviewer says that the requested dental crown is necessary. Our physician reviewer found a review of the enrollee's dental record and radiographs indicate recurrent caries requiring the crown replacement. Caries was noted on the mesial margin of the bitewing radiograph. In order to treat this, the crown would have to be removed to assure that the caries has been removed, thus requiring a crown replacement.

Due to recurrent caries at the mesial margin of the crown, the criteria for a replacement crown for tooth #19 (D2752) 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 a dental crown have been met. Therefore, we decided that the Plan has to pre-approve a dental crown (D2752) on tooth # 19.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia (J0897).

You asked the Plan to pre-approve Prolia. You say that the drug is medically necessary. The Plan denied your request. The Plan says the drug is not being prescribed for a medically-accepted indication.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved 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 Prolia. Our reviewer says that the service is not medically necessary. Our physician reviewer found the requested drug is not FDA-approved for the enrollee's diagnosis. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have not been met. Specifically, the use of the drug is not supported by any of the compendia for the enrollee's diagnosis. This means the drug is not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve Prolia (J0897).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a dental bone graft.

You asked the Plan to pre-approve the graft. 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. 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 a dental bone graft.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve porcelain ceramic crown (D2740) lower partial-resin base (D5212).

You asked the Plan to pre-approve the dental services. You say that you are appealing the decision not to reimburse you for dental expenses. You asked the provider and she said without her knowledge she was removed from provider enrollment. The Plan denied your request. The Plan says if you go to a provider who is not eligible to participate in Medicare, you will be responsible for the full cost of the services you receive.

The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. 

The services at issue in this appeal are to be provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pre-approve porcelain ceramic crown (D2740) lower partial-resin base (D5212).
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 your needs are too high at the moment to be cared for at home. You need a continued hospital stay with intensive therapy. The Plan denied your request. The Plan says the records show that you are medically stable and do not require close physician supervision in the hospital setting.

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 enrollee underwent a scheduled transcutaneous aortic valve replacement. She currently requires moderate assistance for bed mobility and maximal assistance of two for bed to chair transfers. The enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to be able to perform fifteen hours per week of rehabilitative services with regular physician evaluation.

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.