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

We decided that the Plan does not have to pre-approve Pregabalin.

You asked the Plan to pre-approve Pregabalin. You say that the medication is necessary. The Plan denied your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy benefit managed by the plan, therefore self-administered drugs do not meet the criteria for 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 Pregabalin.

Benefits for Pregabalin 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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical team conference, fall risk assessment, Influenza immunization, systolic blood pressure, diastolic blood pressure, and eligible clinician attests to documenting in the medical record they obtained, updated, or reviewed provided on November 6, 2020 by an OON provider.You asked the Plan to pay for the medical team conference, fall risk assessment, Influenza immunization, systolic blood pressure, diastolic blood pressure, and eligible clinician attests to documenting in the medical record they obtained, updated, or reviewed. You say that the enrollee was receiving care from your providers because they are able to go to the enrollee's place of assisted living.The Plan denied your request. The Plan says these services were rendered by a non-participating provider. The Plan also says that prior authorization was not obtained.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 pay for 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 did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay for the medical team conference, fall risk assessment, Influenza immunization, systolic blood pressure, diastolic blood pressure, and eligible clinician attests to documenting in the medical record they obtained, updated, or reviewed provided on November 6, 2020 by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical extraction provided on November 17, 2020.

You asked the Plan to pay for the surgical extraction. You say that this service should be covered because you have a problem with your teeth and need immediate dental surgery. The Plan denied your request. The Plan says this service is not covered. The Plan also says that no misinformation was given to the provider prior to this service being rendered.

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, you are responsible for 100% of the cost for Class 3 Major Services. Therefore, we decided that the Plan does not have to pay for the surgical extraction provided on November 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the occlusal orthotic device (D7880) provided on February 15, 2021.

You asked the Plan to pay for the occlusal orthotic device. You say that you believe this service should be covered. The Plan denied your request. The Plan says this service is not a covered benefit under your dental plan. The Plan also says that you did not contact the Plan prior to this date of service, and the dental rider was not active.

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 occlusal orthotic device (D7880) provided on February 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home ventilator.
You asked the Plan to pre-approve a home ventilator. You say that the requested home ventilator is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for a home ventilator.
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. 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 home ventilator. Our reviewer says that the enrollee does not meet criteria for a home ventilator. Our physician reviewer found the review has determined that the denial for a home ventilator is consistent with Medicare regulations. Per the coverage criteria: the use of a ventilator for treatment of conditions described in the LCD will be denied as not reasonable and necessary. The review has determined that the enrollee does not meet the coverage criteria detailed in the LCD for the requested home ventilator. 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 home ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a home ventilator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 1 power wheelchair with battery and battery charger.You asked the Plan to pre-approve the group 1 power wheelchair and accessories. You say that you would like reconsideration because you have had multiple heart surgeries and will not have the strength to move around with a regular wheelchair.The Plan denied your request. The Plan says the documentation does not show that you have difficulty completing MRADLs, that you are unable to use a walker/cane or that your home can accommodate a power wheelchair.The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 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 group 1 power wheelchair and accessories. Our reviewer says that the documentation is not specific as to what MRADLs in the home are impacted. You are able to use a cane, walk 50 ft and have not tried a manual wheelchair. Our physician reviewer found the wheelchair is noted to be needed mainly outside of the home and the documentation is not clear that the requested wheelchair can be safely maneuvered in the home or that it will significantly improve your ability to participate in MRADLs in the home.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 group 1 power wheelchair and accessories have not been met.Therefore, we decided that the Plan does not have to pre-approve a group 1 power wheelchair with battery and battery charger.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Palonosetron.
You asked the Plan to pre-approve Palonosetron. The Plan denied your request. The Plan says the enrollee does not have a chemotherapy regimen that is associated with a moderate to high potential for nausea/vomiting.
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 palonosetron. Our physician reviewer found that the enrollee as stage IV carcinoma of the anus. The requested use of Palonosetron is not FDA-approved for the enrollee's diagnosis. The use is approved for the treatment of moderate to highly emetogenic chemotherapy. Mitomycin and fluorouracil are low emetogenic potential. The requested use is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. The use is not listed as not indicated, not supported or not recommended in any of the compendia. The documentation does not support that the requested drug is safe and effective and otherwise reasonable and 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 have not been met. Therefore, we decided that the Plan does not have to pre-approve Palonosetron.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Percutaneous Vertebral Augmentation.
You asked the Plan to pre-approve Percutaneous Vertebral Augmentation. You say that you would like reconsideration because this procedure is medically necessary. The Plan denied your request. The Plan says the records do not show that the member has an acute or subacute compression fracture in the lower spine region.
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 Percutaneous Vertebral Augmentation. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the records describe the fracture as being chronic with back pain for 5 months. This is not an acute fracture. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Percutaneous Vertebral Augmentation have not been met. Therefore, we decided that the Plan does not have to pre-approve Percutaneous Vertebral Augmentation.
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 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 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 medically necessary. Our physician reviewer found the enrollee was admitted to the hospital with transverse myelitis and had thoracic decompression for repair of a spinal dural arteriovenous malformation (AVM). He is now medically stable with no complex nursing or rehabilitation needs.
He does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. He may benefit from further therapy but does not require an intensive therapy program in an IRF. There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 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.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on December 30, 2020.
You asked the Plan to pay for the ambulance services. You say that you were following the Covid executive order for treatment in place. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on December 30, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on December 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the four implant supported porcelain/ceramic crowns (D6065
x4) provided on February 23, 2021.
You asked the Plan to pay for the implant supported crowns. You say that you believe these services should be
covered. The Plan denied your request. The Plan says these services are not covered under your plan.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the four
implant supported porcelain/ceramic crowns (D6065 x4) provided on February 23, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a computed tomography (CT) of the chest.

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. Medicare rules say that CT scans 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee had a surveillance CT on April 29, 2021 that showed significant increased activity in the right upper lobe and a lymph node and in your colon as compared with the prior Positron Emission Tomography (PET)/ Computed Tomography (CT) scan on October 1, 2019. The enrollee has declined biopsies. Since the prior Computed Tomography (CT) scan and Positron Emission Tomography (PET)/ Computed Tomography (CT) scan showed likely cancer spread, there is no reason to repeat the Computed Tomography (CT) scan at this time, because surveillance has already done what it was intended to do: find likely cancer spread. The chest CT is therefore 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 a computed tomography (CT) of the chest.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve medical nutrition therapy.
You asked the Plan to pre-approve these services. You say that your blood sugar is low and you need to see a dietician. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services only for enrollees with renal disease or diabetes. Records do not show that you suffer from renal disease or diabetes. Therefore, we decided that the Plan does not have to pre-approve medical nutrition therapy.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex Superion Spacer.
You asked the Plan to pre-approve the Vertiflex device. You say that you would like reconsideration because this procedure is safer than other options. The Plan denied your request. The Plan says this procedure is experimental.
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 Vertiflex device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this procedure is not part of a clinical practice guideline and is still considered experimental/investigational. 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 Vertiflex device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex Superion Spacer.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for non-covered ambulance mileage, per mile (e.g., for miles traveled beyond closest appropriate facility) (A0888), provided on January 16, 2021.You asked the Plan to pay for the non-covered ambulance mileage, per mile (e.g., for miles traveled beyond closest appropriate facility) (A0888).You say that you were advised that you were going to be transported to a hospital, but you wanted to be transported to the hospital where your cardiologist was located.The Plan denied your request. The Plan says emergency transportation is covered to the nearest appropriate facility.The Plan must follow Medicare rules.Medicare rules say that Medicare only covers ambulance transportation to the nearest appropriate facility.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the non-covered ambulance mileage, per mile (A0888) have not been met.Specifically, the record shows that you received transportation services beyond the nearest appropriate facility. This means that the additional ambulance mileage is not covered by Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for non-covered ambulance mileage, per mile (e.g., for miles traveled beyond closest appropriate facility) (A0888), provided on January 16, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the prefabricated, locking knee joint orthosis (L1831) provided on October 23, 2020.
You asked the Plan to pre-approve the knee orthosis. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the knee orthosis 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 knee orthosis. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the record indicates that the enrollee has low back pain with radiculopathy. The record does not indicate the enrollee has a contracture of the knee. The elements of the coverage rule 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 knee orthosis have not been met. Therefore, we decided that the Plan does not have to pre-approve the prefabricated, locking knee joint orthosis (L1831) provided on October 23, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide a therapeutic continuous glucose monitoring sensor kit.You asked the Plan to provide a therapeutic continuous glucose monitoring sensor kit. You say that the enrollee needs the CGM sensor kit.The Plan denied your request. The Plan says criteria is not met for a CGM sensor kit.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 nor requires 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 a therapeutic continuous glucose monitoring sensor kit have not been met.Therefore, we decided that the Plan does not have to provide a therapeutic continuous glucose monitoring sensor kit.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a resin and gold crown (D2720) for tooth#8.You asked the Plan to pre-approve the crown. You say that a new crown is necessary for this tooth.The Plan denied your request. The Plan says they have already paid for a crown for this tooth in February 2019. Crowns can only be covered once every 60 months (five years) per tooth.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 can cover one crown per tooth every 60 months.Though the Plan offers a dental benefit in excess of Medicare coverage, the crown is requested in a frequency that is not covered under this benefit. Documentation shows that you had a previous crown provided for this tooth in 2019. Therefore, we decided that the Plan does not have to pre-approve a resin and gold crown (D2720) for tooth #8.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for routine transportation provided on April 22, 2021.
You asked the Plan to pay for the routine transportation. The Plan denied your request. The Plan says the member did not give enough notice for the service to be covered.
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. We looked at your request, the records in the case file, and the rules. The file shows that you requested the routine transportation on April 20, 2021 at 12:59 p.m., which is not 48 hours in advance. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to pay for routine transportation provided on April 22, 2021.