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

 
We decided that the Plan does not have to pre-approve a mandibular partial denture with dental code D5214. 
 
You asked the Plan to pre-approve dental code D5214. You say that you would like the Plan to reconsider their 
denial. The Plan denied your request. The Plan says your benefit for the requested dentures has been exhausted 
for 2021 benefit year. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
We looked at the file, the Plan's contract and Medicare rules. The Plan covers complete and partial dentures 
once every five years. The file shows that you received a partial denture on August 15, 2018, which is less than 
five years ago. You are not yet eligible for new dentures. The Plan says that you do have a 20 to 50% discount 
on a new set of partial dentures since your current denture is broken without repair. The Plan says you can see a 
participating dentist and the discount will be taken off your bill. Therefore, we decided that the Plan does not 
have to pre-approve a mandibular partial denture with dental code D5214.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genetic testing (81162, 81292, 81404, 81408). 
 
You asked the Plan to pre-approve the genetic testing. You say that the testing is medically necessary due to 
family history. The Plan denied your request. The Plan says there is no personal history of cancer, therefore 
coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that testing of individuals with no personal history of 
breast, ovarian, fallopian tube, primary peritoneal, pancreatic, or prostate cancer is considered screening and is 
considered not medically necessary.  
 
We looked at the file and Medicare rules. The record shows only a family history of cancer. There is no 
documentation that the enrollee has a current or previous cancer diagnosis. Based on this information, we 
decided that Medicare rules for coverage of the genetic testing have not been met. Therefore, we decided that 
the Plan does not have to pre-approve genetic testing (81162, 81292, 81404, 81408).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve catheter irrigation supplies (A4320, A4216). 
 
You asked the Plan to pre-approve the catheter irrigation supplies. You say that the supplies are medically 
necessary. The Plan denied your request. The Plan says these items are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that routine intermittent catheter irrigation supplies 
are considered not reasonable and necessary, and therefore are non-covered. 
 
We looked at the file and Medicare rules. The items are for routine intermittent catheter irrigation. Items for 
this purpose are not covered by Medicare. Based on this information, we decided that Medicare rules for 
coverage of the catheter irrigation supplies have not been met. Therefore, we decided that the Plan does not 
have to pre-approve catheter irrigation supplies (A4320, A4216).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS HF system. 
 
You asked the Plan to pre-approve a CardioMEMS HF system. You say that the requested CardioMEMS HF 
system is medically necessary. The Plan denied your request. The Plan says the requested CardioMEMS HF 
system 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 a CardioMEMS HF system. Our 
reviewer says that the requested CardioMEMS HF system is not medically necessary. Our physician reviewer 
found the enrollee is with a diagnosis of Chronic diastolic (congestive) heart failure, as well as hypertrophic 
cardiomyopathy, cardiac amyloidosis, recurrent atrial fibrillation, valvular heart disease, diabetes, vascular 
disease, and sleep apnea. The enrollee was hospitalized with diastolic heart failure in September 2020. 
 
The efficacy of the CardioMEMS heart failure system remains uncertain at this time. Further clinical study is 
needed to determine the efficacy and safety of this device. It is not clear that the CardioMEMS device is 
medically reasonable and necessary for the enrollee in this case. 
 
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 CardioMEMS HF system have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a CardioMEMS HF system.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Infed. 
 
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 iron infusion therapy is covered when specific 
criteria are met. 
 
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 records show that you have 
recurrent iron deficiency. There is no documentation of your blood iron levels (hemoglobin), ferritin, or iron 
saturation percentage. You do not meet the criteria for coverage of Infed and the services are not reasonable or 
medically necessary at this time. 
 
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 Infed.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Renflexis. 
 
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 pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 has rheumatoid arthritis 
without rheumatoid factor of multiple sites. While the documentation supports that Renflexis is reasonable for 
the enrollee, it is not medically necessary, as the Plan's alternatives, REmicade and Inflectra, are not addressed. 
 
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 Renflexis.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician services to be provided by an out of network 
(OON) provider. 
 
You asked the Plan to pre-approve physician services. You say that you have established care and you would 
like to continue to see this doctor. The Plan denied your request. The Plan says there are in-network providers 
available for these services. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and 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 
physician services to be provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary complete denture (D5110). 
 
You asked the Plan to pre-approve the maxillary complete denture. You say that you were not aware that you 
would not have coverage for dentures during the 2021 plan year. The Plan denied your request. The Plan says 
this service is 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 contract says that dentures are only covered under the Optional 
Supplemental Dental plan. The Plan says that you are not enrolled in this supplemental plan. Therefore, we 
decided that the Plan does not have to pre-approve a maxillary complete denture (D5110).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuity of care with an out-of-network vascular surgery specialist.
You asked the Plan to pre-approve specialist service. You say that you are requesting continuation of care. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this provider is out-of-network with the Plan and the enrollee can be treated by an in-network specialist.
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan providers available to meet the enrollees' needs. The enrollee's contract with the Plan says that, with few exceptions, enrollees must use contract providers for 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 specialist service. Our reviewer says that the enrollee does not meet the criteria for continuity of care with the requested out-of-network provider. Our physician reviewer found while the enrollee may have seen this provider in the past, evidence has not been provided that there has been a long history of numerous visits or procedures representative of a close physician relationship, or unique knowledge of the enrollee that would necessitate continuity. The enrollee has basic vascular surgery issues that can be managed by an average vascular surgeon. The Plan has shown that they have in-network specialists who have the qualifications and expertise necessary to meet the current medical standards of care required for treatment of the enrollee's condition. The enrollee's medical management and/or follow-up care can be safely transitioned to an in-network vascular surgery specialist at this time. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of specialist service have not been met. Therefore, we decided that the Plan does not have to pre-approve continuity of care with an out-of-network vascular surgery specialist.
Appeal type: Surgery
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 is medically necessary. The Plan denied your 
request. The Plan says medical studies have not proven that this device is helpful for treatment of the health 
problem. 
 
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 current evidence based medical guideline and peer reviewed literature do not fully support the spinal 
decompression device procedure over the "gold 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 as discussed above. 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 also 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 imaging 
evidence of grade 1 anterolisthesis of L5 on S1 with no discussion of spinal instability on flexion/extension 
films. There is imaging evidence of levoconvex lumbar curvature of the lumbar spine with no documentation of 
the Cobb angle. There is no discussion indicating that a DEXA scan has demonstrated the lack of significant 
osteoporosis in this patient. Therefore, the request for Vertiflex device is 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 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continuous glucose monitor. 
 
You asked the Plan to pre-approve a continuous glucose monitor. You say that the continuous glucose monitor 
is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
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. Based on this information, we decided that Medicare rules for coverage of a 
continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-
approve the continuous glucose monitor.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an upper partial denture (D5225). 
 
You asked the Plan to pre-approve an upper partial denture. You say that you need this service covered. The 
Plan denied your request. The Plan says this service is 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 pre-approve an 
upper partial denture (D5225).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the bilateral breast augmentation surgery (19340, 
19371). 
 
You asked the Plan to pre-approve breast augmentation surgery. You say that you have a congenital defect and 
only one of your breasts grew during puberty. The plastic surgeon is suggesting making them larger in order to 
even them out. The Plan denied your request. The Plan says cosmetic services are not covered by the plan. This 
request is cosmetic in nature and cannot be approved. 
 
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 breast augmentation surgery. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the documentation supports that the proposed surgery is cosmetic in nature, 
rather than 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 breast augmentation surgery have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the bilateral breast augmentation surgery (19340, 19371).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an occlusal guard (D9944). 
 
You asked the Plan to pre-approve the dental item. You say that this is medically necessary. You say that you 
grind your teeth. You say that you also have sleep apnea. You say that you had a sleep study test. You say that 
you have had many failed attempts with C-PAP devices. You also say that the only other option that you can 
tolerate is an occlusal guard. The Plan denied your request. The Plan says occlusal guard is not listed as 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 Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Additionally, the item you are asking the Plan to pre-approve involves 
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 an occlusal guard (D9944).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 5 additional direct skilled nursing services of a RN in the home health or hospice setting (G0299).
You asked the Plan to pre-approve the additional direct skilled nursing services of a RN. You say that you would like additional skilled nursing visits to be approved for coverage. The Plan denied your request. The Plan says the records provided do not document clinical instability or medical management requiring continued home care services.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 additional direct skilled nursing services of a RN. Our reviewer says that the requested home health services are not medically necessary. Our physician reviewer found the documentation does not support that the enrollee requires skilled nursing services or skilled rehab services to provide treatment that is medically necessary. Our reviewer found that the enrollee does not require skilled nursing or rehab services to effectively provide treatment, care, and/or services in order to improve the enrollee's condition, perform a maintenance program to maintain the enrollee's condition and/or prevent deterioration. Our physician reviewer also found that the enrollee has been medically stable without any recent exacerbations of chronic medical problems or hospitalizations. 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 additional direct skilled nursing services of a RN have not been met. Therefore, we decided that the Plan does not have to pre-approve 5 additional direct skilled nursing services of a RN in the home health or hospice setting (G0299).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a raised toilet seat. 
 
You asked the Plan to pre-approve a raised toilet seat. You say that the raised toilet seat is medically necessary. 
The Plan denied your request. The Plan says this is not a covered item. 
 
The Plan covers all items that Medicare covers. Medicare rules state that raised toilet seats are not covered 
because they are not primarily medical in nature.  
 
While a raised toilet seat 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 raised toilet seat.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lightweight wheelchair (E1399).
You asked the Plan to pre-approve the lightweight wheelchair. You say that the wheelchair is medically necessary. The Plan denied your request. The Plan says insufficient information has been provided to support coverage of the wheelchair.
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. We looked at the file and Medicare rules. No medical records were provided to support the request. Without medical records, it cannot be determined if the enrollee meets coverage criteria for a lightweight wheelchair. Based on this information, we decided that Medicare rules for coverage of the lightweight wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve a lightweight wheelchair (E1399).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on November 5, 2020.
You asked the Plan to pay for the laboratory services. 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. If you need medical care that Medicare requires our plan to cover and the providers in our network cannot provide this care, you can get this care from an out-of-network provider. You, or your PCP, must obtain authorization from the plan prior to seeking care.
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 and the ordering provider are not network providers with the Plan. The Plan did not pre-approve the laboratory services. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for laboratory services provided on November 5, 2020.