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

We decided that the Plan does not have to pre-approve Prolensa.
You asked the Plan to pre-approve Prolensa. You say that the medication is necessary. The Plan denied your
request. The Plan says the enrollee has a medical only policy which does not include Part D prescription
coverage, therefore the criteria for self-administered drug coverage has not been met.
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 Prolensa.
Benefits for Prolensa 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 the continued coverage of continuous positive airway pressure (CPAP) device (E0601).
You asked the Plan to pre-approve the continued coverage of CPAP device. You say that continued coverage of the CPAP device is medically necessary. The Plan denied your request. The Plan says the coverage criteria for the CPAP device have not been met.
The Plan follows Medicare rules. Medicare rules say that continued coverage of a CPAP device requires a clinical re-evaluation that the enrollee is benefiting from the device. 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 continued coverage of CPAP device. Our reviewer says that the requested service is not medically reasonable and necessary. Our physician reviewer found the enrollee is a 71-year-old man year old man who has been approved to use the CPAP device for six months in 2020 under another plan and has been using CPAP since 2019. The documentation indicates that in September 2020, he used the device 100% of nights with 90% being more than four hours and average of over six hours per night. However, the record does not indicate that the enrollee has had an in-person clinical evaluation since September 2020 to document ongoing improvement in symptoms. The elements of the coverage determination are not satisfied. 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 continued coverage of CPAP device have not been met. Therefore, we decided that the Plan does not have to pre-approve the continued coverage of continuous positive airway pressure (CPAP) device (E0601).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ForeseeHome monitoring program.
You asked the Plan to pre-approve ForeseeHome monitoring program. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not met.
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 ForeseeHome monitoring program. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found in this case, the provided medical records do not provide sufficient documentation that the prescriber intended to prescribe the device or determined that it was medically necessary and reasonable. The record indicates that the enrollee has not had any change in vision. The elements of the coverage determination are not satisfied. The requested service is not recommended. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of ForeseeHome monitoring program have not been met. Therefore, we decided that the Plan does not have to pre-approve ForeseeHome monitoring program.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve closure of swollen veins of the enrollee's legs with laser
energy (endovenous laser ablation therapy and Closure of swollen veins of the enrollee's legs with radiowaves
(endovenous radiofrequency ablation known as EVRFA) known as EVLAT) (CPT code(s): 36475, 36479,
36476, 36478), for the enrollee.
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your
request. The Plan says the services are not medically necessary.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the services. Our physician reviewer
found the documentation does not meet LCD criteria and does not support the medical necessity of the
procedures in question. There is unsatisfactory documentation that the enrollee is having lifestyle limiting or
mobility limiting symptoms due to the varicose veins. There is also unsatisfactory documentation of a
concerted efforts at conservative treatment. The documentation of arterial perfusion is inadequate considering
the enrollee's age and history of atrial fibrillation, hypertension, and hyperlipidemia. The enrollee also has
numerous other coexisting factors including multiple lower extremity joint replacements and a stent of
unknown location placed in July 2020. CEAP and VCSS classification information is not provided as required
by the LCD. The assessment and plan do not discuss what veins are to be treated and how they are related to
the enrollee's symptoms.
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 services have not been met. Therefore, we decided that the Plan does not
have to pre-approve closure of swollen veins of the enrollee's legs with laser energy (endovenous laser ablation
therapy and Closure of swollen veins of the enrollee's legs with radiowaves (endovenous radiofrequency
ablation known as EVRFA) known as EVLAT) (CPT code(s): 36475, 36479, 36476, 36478), for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a Skilled Nursing Facility (SNF).
You asked the Plan to pre-approve SNF care. You say that you need SNF care to continue with your treatment
as you are losing maximum function. The Plan denied your request. The Plan says the denial of authorization
for SNF care is correct.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section 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 SNF care. Our reviewer says that daily
skilled services are not necessary. Our physician reviewer found you do not have daily skilled nursing needs
that require the specialized skill, knowledge, and judgment of a skilled professional nurse. You do not have
daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional
therapist. You do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a Skilled
Nursing Facility (SNF) 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 SNF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve admission to a Skilled Nursing Facility (SNF).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
You asked the Plan to pre-approve the device. You say that this procedure is highly recommended, as it is a
less invasive procedure. The Plan denied your request. The Plan says a review of the current medical literature
indicates that this service is considered experimental and investigational.
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 device. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found the device is experimental. More research is needed to show safety and efficacy of the device.
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 device have not been met. Therefore, we decided that the Plan does not have
to pre-approve the Vertiflex device for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a dental extraction which will be provided by an oral
surgeon.
You asked the Plan to pre-approve services provided by an oral surgeon. You say that your dentist
recommended an oral surgeon complete this procedure. You are in pain and on blood thinners. You were
advised that your tooth is broken. The Plan denied your request. The Plan says services provided by an oral
surgeon are not covered. All supplemental dental services must be provided by a general dentist.
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, services will only be covered if they
are provided by a participating general dentist. Therefore, we decided that the Plan does not have to preapprove
a dental extraction which will be provided by an oral surgeon.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve MRI of the lumbar spine.

You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your request. The Plan says there is no history of physical therapy or exercises attempted.

The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically necessary. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the MRI. Our reviewer says that the requested MRI is not medically reasonable or necessary. Our physician reviewer found there are no red flags for MRI present. There is no documentation of a recent trial of physical therapy for back pain. 

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 MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve MRI of the lumbar spine.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a consultation and multiple extractions to be provided by an oral surgeon.

You asked the Plan to pre-approve the consultation and extractions. You say that you need these services to be approved for coverage. The Plan denied your request. The Plan says dental services are only covered when they are performed by a participating general dentist. The Plan also says that dental services performed by an oral surgeon 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 covered when they are received by anyone other than a participating general dentist. Therefore, we decided that the Plan does not have to pre-approve a consultation and multiple extractions to be provided by an oral surgeon.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a stair lift.

You asked the Plan to pre-approve a stair lift. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested 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 lift.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (D2750) and core buildup (D2950).
You asked the Plan to pre-approve the crown and core buildup. You say that these services are medically necessary. The Plan denied your request. The Plan says these services are not covered by Medicare or by 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 a crown (D2750) and core buildup (D2950).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 3-dimensional (3D) rendering for Magnetic Resonance Imaging (MRI).
You asked the Plan to pre-approve 3D rendering. You say that you are in need of this test to further the enrollee's treatment. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because 3D rendering is not medically necessary for the approved MRI.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve 3D rendering. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested MRI 3D rendering. Our physician reviewer found the records provided do not document the medical necessity and reasonableness of the requested 3D rendering. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 3D rendering have not been met. Therefore, we decided that the Plan does not have to pre-approve 3-dimensional (3D) rendering for Magnetic Resonance Imaging (MRI).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Freestyle Libre.

You asked the Plan to pre-approve Freestyle Libre. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says you do not meet criteria for the requested device.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. 

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of Freestyle Libre have not been met. Therefore, we decided that the Plan does not have to pre-approve Freestyle Libre.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet joint injection for the enrollee.

You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says the lumbar pain radiates to both lower extremities, therefore, there is evidence of a radicular component to the pain.
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 injection. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has multiple pain generators including foraminal stenosis and spinal stenosis. The criteria is therefore not met. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the injection have not been met. Therefore, we decided that the Plan does not have to pre-approve facet joint injection for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pulp cap (D3110) and core build up (D2950).

You asked the Plan to pre-approve the dental services. You say that you need these services to be approved. You say that you need these services to treat a dental infection. The Plan denied your request. The Plan says pulp cap is not listed as a covered service. The Plan says that core build up 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 pre-approve a pulp cap (D3110) and core build up (D2950).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the pneumatic compression device to be provided by an
OON provider.

You asked the Plan to pre-approve the pneumatic compression device. You say that you would like this claim
reconsidered for medical necessity. The Plan denied your request. The Plan says although the requested device
is medically necessary, the device is available from an in-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 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 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 pneumatic compression device to be provided by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a 20-inch wide walker from an out-of-network provider.

You asked the Plan to pre-approve these services. You say that you are having a knee replacement and need a new walker. 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 supplier must have an order from the treating physician before dispensing any DMEPOS item to a beneficiary. The rules say that Medicare pays for services only when they are furnished by a provider or supplier enrolled in the Medicare program. 

We looked at the file and Medicare rules. There is no valid physician order for the requested item. Furthermore, the requested provider is not a Medicare-certified provider. 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 20-inch wide walker from an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an occlusal guard (D9946).
You asked the Plan to pre-approve the occlusal guard. You say that this item is necessary, and you cannot
afford the cost. The Plan denied your request. The Plan says this item is not covered by Medicare or by your
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 an
occlusal guard (D9946).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a travel CPAP device.

You asked the Plan to pre-approve a travel CPAP. You say that the requested device is imperative for the
enrollee's safety during overnight sailboat racing. The Plan denied your request. The Plan says rules for a
CPAP device have not been met.

The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate
and needed for use inside the home.

The case record indicates that the item at issue in this appeal is for use outside of the home. Although this item
may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we
decided that the Plan does not have to pre-approve a travel CPAP device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a removal of a bone overgrowth on the lower jaw (D7473).

You asked the Plan to pre-approve a removal of a bone overgrowth on the lower jaw. You say that you want to see this provider for the service at issue. The Plan denied your request. The Plan says the provider is out-of-network and is not covered by the Plan. You must utilize participating providers.

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 a removal of a bone overgrowth on the lower jaw 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 a removal of a bone overgrowth on the lower jaw (D7473).