Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for Inpatient Mental Health services provided November 14, 2019 to November 20, 2019.You asked the Plan to pay for the inpatient mental health services. You say that the services were medically necessary.The Plan denied your request. The Plan says services could have been provided at a lower level of care.The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the inpatient mental health services. Our reviewer says that coverage criteria has not been met for services provided after November 14, 2019. Our physician reviewer found upon review the records provided for the admission of this patient does not meet the criteria for continued acute inpatient mental health treatment for the dates in question of November 14, 2019 forward as this patient was not shown to be a danger to herself or others. She was not showing any auditory or visual hallucinations and was cooperative/compliant with treatment.
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 inpatient mental health services have not been met.Therefore, we decided that the Plan does not have to pay for Inpatient Mental Health services provided November 14, 2019 to November 20, 2019.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve a crown (D2750) for teeth # 20, and 21, a metal upper partial denture (D5213), and a metal lower partial denture (D5214). You asked the Plan to pre-approve the crown for teeth # 20 and 21, and partial upper and lower dentures. You say that the crown is covered under your dental services. You say that you are going to lose your tooth if you don't have a crown. You say that you need the post and core because you cannot get the crown without it. You also say that if the crown is covered, the post and core should be covered too.The Plan denied your request. The Plan says that the crowns for teeth # 20 and 21 are not medically necessary due to a lack of enough breakdown. The Plan says that many of your teeth have large fillings and are not strong enough to hold an upper metal partial denture. The Plan also says that you do not have enough healthy front and back teeth on the lower half of your mouth and therefore the lower metal partial denture is not medically 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 the crown for teeth # 20and 21, and partial upper and lower dentures 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 the crown for teeth # 20 and 21, and partial upper and lower dentures. Our reviewer says that the requested dental services are medically necessary. Our physician reviewer found that teeth # 20 and 21 meet the criteria for crowns due to the weakened state of the coronal structure. Also, the criteria for partial dentures meet the criteria for coverage due to the compromised masticatory function resulting from the number of missing maxillary and mandibular teeth.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the crown for teeth # 20 and 21, and partial upper and lower dentures have been met.Therefore, we decided that the Plan has to pre-approve a crown (D2750) for teeth # 20, and 21, a metal upper partial denture (D5213), and a metal lower partial denture (D5214). 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprove a pneumatic compression device (E0652).
You asked the Plan to preapprove a pneumatic compression device. You say that you have swelling in your legs. The Plan denied your request. The Plan says the documentation did not support that there is truncal swelling or the 4-week trial using the basic pump that Medicare requires.
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting,
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. Therefore, we decided that the Plan does not have to preapprove a pneumatic compression device (E0652).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprove a pneumatic compression device (E0652).
You asked the Plan to preapprove a pneumatic compression device. You say that the enrollee requires the device. The Plan denied your request. The Plan says the documentation did not support that there was truncal swelling or that there was the 4-week trial using the basic pump that Medicare requires.
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required.
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. Therefore, we decided that the Plan does not have to preapprove a pneumatic compression device (E0652).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a replacement spinal cord stimulator (SCS) implant.
You asked the Plan to pre-approve a replacement SCS implant. You say that this should be covered. The Plan denied your request. The Plan says the records do not show proof that the current stimulator was tested and does not work.
The Plan follows Medicare rules. Medicare rules say that SCS implants are covered only according to the LCD rules noted above. 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 replacement SCS implant. Our reviewer says that the requested SCS implant is not medically necessary. Our physician reviewer found clinical practice guidelines do not support the placement of additional spinal cord stimuator generator. While additional leads may be placed or changed, there is no indication for an additional SCS. 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 replacement SCS implant have not been met. Therefore, we decided that the Plan does not have to pre-approve a replacement spinal cord stimulator (SCS) implant.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea Group 2 standard power wheelchair and accessories.You asked the Plan to pre-approvea Group 2 standard power wheelchair and accessories. Yousay that the enrollee is unable to ambulate short distances and has a difficulty self-propelling a manual wheelchair.The Plan denied your request. The Plan says the enrollee is in an institution that is part of a skilled nursing facility and not entitled to separate Part B payments.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home. Records show that a Group 2 standard power wheelchair and accessories is being requested for use in a SNF.Therefore, we decided that the Plan does not have to pre-approvea Group 2 standard power wheelchair and accessories.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea shower chair.You asked the Plan to pre-approvea shower chair. You say that you have problems with your hip and femur. You say that you live alone and the requested chair should be provided as a preventative measure.The Plan denied your request. The Plan says this item is not a covered benefit.The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item.Therefore, we decided that the Plan does not have to pre-approvea shower chair
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe medical services to be provided by out of network provider, "the doctor".You asked the Plan to pre-approvespecialist office visit. You say that you did not want to go to your PCP for a referral because your PCP could not diagnose you mini stroke.The Plan denied your request. The Plan says there are in-network providers available for the service in question.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-approvethe medical services to be provided by out of network provider,"the doctor".
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Stivax System (L8679). You asked the Plan to pre-approve the Stivax System. You say that this service is medically necessary. The Plan denied your request. The Plan says the records do not indicate that the member meets Medicare coverage criteria for this service.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 Stivax System. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this is an experimental/ investigational device for cervical radicular pain. The patient has not had an MRI, surgery or psychological evaluations.We looked at thisphysician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Stivax System have not been met. Therefore, we decided that the Plan does not have to pre-approve the Stivax System (L8679).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a stair glide.You asked the Plan to pre-approve a stair glide. You say that you do not have good mobility and have to crawl on the stairs to move between levels in your home. You say that if there is a fire, you would have difficulty getting out.The Plan denied your request. The Plan says this item is not a covered benefit.The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they are not primarily medical in nature. While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item.Therefore, we decided that the Plan does not have to pre-approve a stair glide.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea partial upper denture (D5213), and a partial lower denture (D5214).You asked the Plan to pre-approvethe dental services. You say that you have an uncomfortable feeling. You also say that it is very hard to chew without front teeth.The Plan denied your request. The Plan says services provided by a non-contracted dentist are not 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.Though the Plan offers a dental benefit in excess of Medicare coverage, partial dentures are not covered when they are provided by a non-contracted dentist.Therefore, we decided that the Plan does not have to pre-approvea partial upper denture (D5213), and a partial lower denture (D5214)
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve chiropractic manipulation.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 does not cover chiropractic maintenance care. 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 submitted records show that you have had regular chiropractic care since 1975. You have a history of scoliosis and back pain with degenerative disease and severe spinal canal narrowing (stenosis). The records show that you exhibit chronic complaints and significant arthritic and degenerative changes of the spine for which chiropractic therapy can do little to help. The services would be non-covered maintenance therapy and are not reasonable or medically 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 these services have not been met.Therefore, we decided that the Plan does not have to pre-approve chiropractic manipulation.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe voice therapy services to be provided by an out of network provider.You asked the Plan to pre-approvethe outpatient voice therapy services. You say that you want to be referred to "the provider" for vocal problems due to a vocal tremor. You say that she has a unique ability for treating singing voice problems. You also say that "the plan" does not offer any similar treatment.The Plan denied your request. The Plan says the requested services are available in network.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and 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-approvethe voice therapy services 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 a power seat elevation system (E2300).You asked the Plan to pre-approve the power seat elevation system. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the seat elevator does not service a primary medical purpose and is statutorily non-covered.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This itemis available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation system (E2300).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea root canal to be provided by the provider.You asked the Plan to pre-approvethe dental service. You say that you were hit in the face by a tree limb in 2016. You also say that this event caused tooth nerve damage.The Plan denied your request. The Plan says root canals are not 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 Planoffers a dental benefit in excess of Medicare coverage, a root canal is not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approvea root canal to be provided.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a repeat echocardiogram.You asked the Plan to pre-approve the repeat echocardiogram. You say that you are having problems with the medication you are on and need this test to figure out what is going on with your heart.The Plan denied your request. The Plan says the need for the requested exam is not supported because there were no current up-to-date doctor's office notes less than 6 months old.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 repeat echocardiogram. Our reviewer says that a repeat echocardiogram not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee had a nonischemic cardiomyopathy with a return to a low normal LVEF on three separate cardiac imaging tests spanning a 2-year period (September 2013 -September 2015.) Our physician reviewer found that the enrollee has no documented heart failure symptoms and no murmurs on cardiac physical exam. Our physician reviewer found that in this setting of a stable, near completely resolved cardiomyopathy with no symptoms of congestive heart failure and no murmur a repeat echocardiogram is not indicated or medically 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 repeat echocardiogram have not been met.Therefore, we decided that the Plan does not have to pre-approve a repeat echocardiogram.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean Omnipod Dash pack pod for the enrollee.You asked the Plan to pre-approvethe Omnipod Dash. The Plan denied your request. The Plan says the requested item is not covered under the Medicare Part B 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-approvean Omnipod Dash pack pod.Benefits for the Omnipod Dashmay 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: Favorable

We decided that the Plan has to pre-approve porcelain retainer crowns for tooth #'s 7 and 10 and pontics for tooth #'s 8 and 9 to be provided by you.You asked the Plan to pre-approve the retainer crowns and pontics. You say that the enrollee needs to use his fixed prosthesis benefits to restore the teeth that can be salvaged and replace the teeth to be removed.The Plan denied your request. The Plan says that the information provided does not indicate why a denture cannot be used to replace the enrollee's missing 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. The Plan covers the retainer crowns and pontics when the services are medically necessary and reasonable.We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the retainer crowns and pontics have been met. The Plan did not clearly disclose that removable dentures are preferred to fixed bridgework. The Plan also did not provide digital x-rays that were requested.Therefore, we decided that the Plan has to pre-approve porcelain retainer crowns for tooth #'s 7 and 10 and pontics for tooth #'s 8 and 9 to be provided by you.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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 12 outpatient speech therapy services. You asked the Plan to pre-approve the speech therapy. You say that additional speech therapy is medically necessary. The Plan denied your request. The Plan says the information submitted fails to meet medical necessity criteria for additional speech therapy treatments.The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 speech therapy. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found there is no indication that the member could not safely utilize swallow techniques taught by speech therapy. Additionally, the record does not indicate that the member has significantly benefited from prior speech therapy services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the speech therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve 12 outpatient speech therapy services