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

We decided that the Plan does not have to pre-approve the ColoGuard testing.
You asked the Plan to pre-approve the Cologuard testing. You say that you feel this is medically necessary since your provider ordered it for you. The Plan denied your request. The Plan says you do not meet the age criterion for coverage of this screening by Medicare.
The Plan must follow Medicare rules. Medicare rules say that ColoGuard screening for colorectal cancer is covered for asymptomatic patients with average risk of cancer who are between 55-85 years of age. The file shows that you are over 85 years of age as of the date of this request. As such, Medicare coverage for this screening is not allowed. Therefore, we decided that the Plan does not have to pre-approve the ColoGuard testing.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Retacrit for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says this is 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 the drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found the documentation does not support that Retacrit is medically reasonable or necessary for the enrollee based on the high erythropoietin level recently checked. The documentation does not support that Retacrit would be effective with high levels of erythropoietin already present. Current evidence found in the Medicare-supported compendia supports only using Retacrit when erythropoietin levels are less than 500 mU/mL in the setting of lower-risk MDS which doesn't apply to this enrollee at this time. The enrollee's prescribing physician did not provided sufficient supportive information to make a case for this enrollee being an exception. 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 drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Retacrit for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hearing aids to be purchased from an out of network
provider.
You asked the Plan to pre-approve hearing aids. You say that you feel that if your audiologist is in network
with the medical plan then their other models of hearing aids that they offer should be covered with more than
just $500 being paid toward them. The Plan denied your request. The Plan says hearing aids that are not
TruHearing brand hearing aids are not covered.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that
exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for
only Truhearing brand hearing aids when purchased from a TruHearing or any provider.
We looked at this the file and the Plan's rules. Based on this information, we decided that the Plan's rules for
coverage of hearing aids have not been met. Therefore, we decided that the Plan does not have to pre-approve
hearing aids to be purchased from an out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the requested physician's services for an eye exam.
You asked the Plan to pre-approve physician's services for an eye exam. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.
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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve the requested physician's services for an eye exam.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have topreapprovea pneumatic compression device (E0652).You asked the Plan to preapprovea pneumatic compression device. You say that you require the device.The Plan denied your request. The Plan says the physician's note does not mention core or trunk edema.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 preapprovea pneumatic compression device (E0652).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe core buildup (D2950).You asked the Plan to pre-approvethe core buildup (D2950). You say that full coverage should be approved for the necessary treatment.The Plandenied your request. The Plan says the 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-approvethe core buildup (D2950).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the requested physician's services.
You asked the Plan to pre-approve the physician's services. You say that you are not satisfied with the service
you received from the Plan provider as you feel this provider is not knowledgeable enough and wanted to do
cortisone shots before surgery, which you do not prefer to do. The Plan denied your request. The Plan says the
service is available within the primary network and member's condition is not an emergency.
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 services at issue in this appeal. We found no exception that would require the
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve the
requested physician's services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuing inpatient mental health care.You asked the Plan to pre-approve inpatient mental health services. You say that the services continue to be medically necessary.The Plan denied your request. The Plan says services can be 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 pre-approve inpatient mental health services. Our reviewer says that the services are not medically necessary. Our physician reviewer found based upon review the records provided it was not expected this enrollee would improve in a reasonable period of time for the dates in question as she did not have suicidal or homicidal ideation noted and denied any auditory or visual hallucinations. The patient was compliant with treatment while not showing any acute threats to safety.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient mental health services have not been met.Therefore, we decided that the Plan does not have to pre-approve continuing inpatient mental health care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Topical Hyperbaric Oxygen Chamber (A4575).
You asked the Plan to pre-approve the Topical Hyperbaric Oxygen Chamber. You say that the item is
medically necessary. The Plan denied your request. The Plan says topical hyperbaric oxygen chambers are not
covered.
The Plan must follow Medicare rules. Medicare rules say that topical hyperbaric oxygen chambers are not a
covered benefit.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the Topical Hyperbaric Oxygen Chamber have not been met. Therefore, we decided that the Plan
does not have to pre-approve a Topical Hyperbaric Oxygen Chamber (A4575).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Albuterol Sulfate 90 mcg inhaler.
You asked the Plan to pre-approve the Albuterol inhaler. You say that the medication is medically necessary.
The Plan denied your request. The Plan says this drug is not eligible for coverage under the Part B medical
benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 Albuterol Sulfate 90 mcg
inhaler.
Benefits for the Albuterol inhaler may be available under Medicare Part D. Contact the Plan that administers
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a backup battery for a CPAP (A9270).
You asked the Plan to pre-approve the battery. You say that the battery is medically necessary because your
area is prone to power outages. The Plan denied your request. The Plan says backup batteries and generators
are not eligible for Medicare coverage.
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 item is
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 backup battery for a CPAP (A9270).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a battery for your power scooter.
You asked the Plan to pre-approve a battery. You say that you fell down outside your house because you were
unable to use your scooter. The Plan denied your request. The Plan says that this is not medically necessary.
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 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 battery for your power scooter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve partial lower dentures and partial upper dentures.
You asked the Plan to pre-approve the partial dentures. You say that your front tooth is bothering you and is
painful following a filling that was done in June of 2020. You say that you have had to take a pain killer to
soothe the pain. You say that you can only eat soft food and are having a hard time biting because you are a
diabetic. You say that you cannot eat properly. The Plan denied your request. The Plan says the benefit for
partial dentures is currently exhausted.
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 benefit for dentures is limited to
one set every 5 years. The records show that you received coverage for a set of partial lower dentures on
September 6, 2016. The records also show that you received coverage for a set of partial upper dentures on
December 18, 2017. This means that it has been less than 5 years since you last received coverage for dentures,
and that your request would exceed the benefit allowance. Therefore, we decided that the Plan does not have to
pre-approve partial lower dentures and partial upper dentures.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 testing provided on February 7, 2020.
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the services were billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that Guardant360 testing must be reported with one unit of CPT 81479 and the appropriate DEX Z-Code. We looked at the file and Medicare rules. The requested Guardant360 testing was billed with multiple CPT codes. Per the applicable article, this testing must be reported with CPT 81479 and the appropriate DEX Z-Code. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay for the Guardant360 testing provided on February 7, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids provided to you by an out-of-network provider on January 17, 2020.You asked the Plan to pay for the hearing aids. The Plan denied your request. The Plan says 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 has network providers available who can provide the items at issue in this appeal. The Plan did not pre-approve the items at issue. We found no exception that would require the Plan to pay for these items.Therefore, we decided that the Plan does not have to pay for the hearing aids provided to you by an out-of-network provider on January 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the crown (D2740) for tooth #5.
You asked the Plan to pre-approve the crown (D2740) for tooth #5. You say that the current crown has too
much room and is constantly getting food trapped behind it. The Plan denied your request. The Plan says this
service is only allowed one procedure per tooth every five plan years.
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 Plan also has a maximum benefit
of one crown per tooth every five plan years. The Plan paid for a crown for tooth #5 received on March 22,
2019, which exhausted the benefit. Therefore, we decided that the Plan does not have to pre-approve the crown
(D2740) for tooth #5.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a grab bar.
You asked the Plan to pre-approve a grab bar. You say that you have cerebral palsy you need grab bars
installed in the bathroom and over your bed. 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 grab bars are not covered because
they are not primarily medical in nature.
While a grab bar 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 grab bar.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the complete upper denture and lower partial denture.
You asked the Plan to pre-approve the complete upper denture and lower partial denture. You say that this is a medical necessity. You say that you were informed it would be covered. The Plan denied your request. The Plan says the services are not covered benefits.
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 the complete upper denture and lower partial denture.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional speech therapy (92507) visits.
You asked the Plan to pre-approve additional speech therapy visits. You say that without therapy, the enrollee
is a risk of a decreased quality of life. The Plan denied your request. The Plan says additional speech therapy is
not medically necessary.
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 additional speech therapy visits. 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 speech-language pathology services provided for
chronic disorders of memory and orientation are covered services when significant functional progress is
demonstrated at early stages of the disorder. Her objectively measured scores have not changed significantly.
The enrollee does not meet criteria for coverage for continued speech therapy.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of additional speech therapy visits have not been met. Therefore, we decided that
the Plan does not have to pre-approve additional speech therapy (92507) visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radio frequency nerve ablation.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 documentation does not show the proper pain reduction.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 underwent diagnostic medial branch block where there was a 62% pain reduction in pain. The diagnostic testing does not meet the standard criteria for a positive result. Therefore, the request is considered not medically necessary or reasonable.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 radio frequency nerve ablation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an extra heavy-duty rollator.
You asked the Plan to pre-approve the rollator. You say that the previous wheelchair was defective. The Plan
denied your request. The Plan says this same item was received less than five years ago.
The Plan must follow Medicare rules. Medicare rules say that durable medical equipment cannot be replaced
sooner than five years.
You previously received a rollator in December 2019. Based on this information, we decided that Medicare
rules for coverage of the rollator have not been met. Therefore, we decided that the Plan does not have to preapprove
an extra heavy-duty rollator.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvebilateral L5-S1 transforaminal epidural steroid injection for the enrollee.You asked the Plan to pre-approvethe injection. You say that this is medically necessary.The Plan denied your request. The Plan says there is no MRI or advanced imaging demonstrating spinal stenosis or nerve root compression.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 injection is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no recent imaging. There is inadequate documentation of an acute radiculopathy. Therefore, the request is considered not medically reasonable or necessary.We lookedat 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-approvebilateral L5-S1 transforaminal epidural steroid injection for the enrollee.