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

We decided that the Plan does not have to pre-approve a removal of torus mandibularis (D7473).

You asked the Plan to pre-approve the removal of torus mandibularis. The Plan denied your request. The Plan says this service is not covered under the enrollee's benefit 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 pre-approve a removal of torus mandibularis (D7473).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acupuncture treatment.

You asked the Plan to pre-approve the treatment. You say that you want to try this for psoriatic arthritis. The Plan denied your request. The Plan says this is only covered for low back pain and migraines.

The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the Plan's rules apply in this case. 

We looked at the file and Medicare rules. This is not being requested for low back pain. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Therefore, we decided that the Plan does not have to pre-approve acupuncture treatment.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an immediate maxillary partial denture (D5221).

You asked the Plan to pre-approve the immediate maxillary partial denture. You say that you would like this service to be reconsidered for coverage. The Plan denied your request. The Plan says this service is not covered under the enrollee's benefit 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 pre-approve an immediate maxillary partial denture (D5221).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc-One.

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 Synvisc-One 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 enrollee has right knee pain due to osteoarthritis as documented on radiologic imaging. The submitted records do not clearly document that she has tried and failed at least three months of conservative therapy. The criteria for coverage are not met; therefore, the Synvisc-One is 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 Synvisc-One.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a wig.

You asked the Plan to pre-approve a wig. You say that you will be losing your hair after cancer treatment and will need a wig. The Plan denied your request. The Plan says this is not a covered service.

Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are ordered by a physician. The Plan follows these same rules. 

In this case, although the wig may be appropriate, it does not meet the definition of the above benefit categories. It is not considered DME because it does not directly treat a medical condition. It does not meet the Medicare definition of a prosthetic because it does not replace an internal body organ or attached tissue. As such, it is noncovered by Medicare. Furthermore, the Plan does not offer a supplemental benefit which would provide coverage for a wig. Therefore, we decided that the Plan does not have to pre-approve a wig.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vraylar.

You asked the Plan to pre-approve Vraylar. The Plan denied your request. The Plan says drug coverage is
limited only to those drugs covered under the enrollee's 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 Vraylar.

Benefits for Vraylar 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xeljanz.

You asked the Plan to pre-approve Xeljanz. You say that the enrollee is currently in remission from his rheumatoid arthritis. The Plan denied your request. The Plan says Xeljanz to be administered at home is not covered under the Part B benefit.

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 Xeljanz.

Benefits for Xeljanz 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an unlisted maxillofacial prosthetic procedure (21089) to treat temporomandibular joint (TMJ) syndrome.

You asked the Plan to pre-approve the unlisted prosthetic procedure. You say that this treatment is medical in nature; the occlusal splint will relieve the enrollee's myofascial pain and prevent further degeneration of the enrollee's TMJ. The Plan denied your request. The Plan says that the requested device, described as "oral splint, nightguard" in the request, is more accurately described as an occlusal orthotic device (D7880). An oral splint is always considered dental rather than medical, and therefore is not covered by Medicare. There is insufficient information to show that this service is medical in nature and should be covered by Medicare. Additionally, nightguards and oral splints are not covered by the Plan's supplemental dental benefit.

The Plan must follow Medicare rules. The rules say that Medicare covers treatment for TMJ syndrome only when the condition or symptom is medical in nature. The treatment must also be medically reasonable and necessary. This device is requested for TMJ. Additional medical diagnoses were provided along with medical records. However, based on the description of the requested item it is unclear if the oral splint qualifies for medical coverage, as oral occlusal appliances used to treat TMJ disorders are excluded from Medicare coverage.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, we have also reviewed the Plan's coverage rules in this case.

We looked at the file and Medicare rules. Based on this information, we cannot prove that the Medicare rules for coverage of the unlisted prosthetic procedure have been met. 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 unlisted maxillofacial prosthetic procedure (21089) to treat temporomandibular joint (TMJ) syndrome.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve whole body bone/joint imaging and a computed tomography (CT) scan of the abdomen/pelvis.

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 items and services that are not medically necessary are not covered. 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 has a diagnosis of prostate cancer. Magnetic resonance imaging (MRI) of the prostate showed a PI-RADS 5 lesion in the left peripheral zone abutting left transition zone, no nodal or osseous metastases. A repeat biopsy revealed a Gleason score of 3+3=6, group 1 disease, and seven out of 24 positive cores. The National Comprehensive Cancer Network (NCCN) guidelines do not recommend advanced imaging workup in this instance, as the chance of metastases is less than 10 percent and the prostate specific antigen is not more than 20. The CT scan and whole body imaging are not reasonable or medically necessary. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve whole body bone/joint imaging and a computed tomography (CT) scan of the abdomen/pelvis.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF).
You asked the Plan to pre-approve continuation of SNF care. You say that SNF care continues to be medically
necessary. The Plan denied your request. The Plan says the criteria for SNF care is no longer met.
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 continuation of SNF care. Our reviewer
says that daily skilled services are not necessary. Our physician reviewer found the enrollee is a 79-year-old
female whose last covered day of SNF coverage was April 14, 2021. The enrollee does not have documented
skilled therapy needs. Daily skilled services are not required to establish a maintenance program or to prevent
deterioration of the enrollee's condition. The enrollee's care needs at this point are custodial and, as a practical
matter, can be provided at a lower level of care
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of continuation of SNF care have not been met. Therefore, we decided that the
Plan does not have to pre-approve the continuation of skilled nursing facility (SNF).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that it is felt that LTACH is medically necessary for this patient. The Plan denied your request. The Plan says the enrollee's needs are being met in the current facility.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The review indicates that the enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (D2740), provisional crown (D2799), and core
buildup, including any pins when required (D2950).
You asked the Plan to pre-approve the crown, provisional crown, and core buildup. You say that you would
like these services to be approved for coverage. The Plan denied your request. The Plan says these services are
not covered under your benefit 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 pre-approve a
crown (D2740), provisional crown (D2799), and core buildup, including any pins when required (D2950).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is 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 considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found based on the medical records provided the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does require physical therapy and occupational therapy services but based on the medical records provided the enrollee does not require an intensive inpatient rehabilitation therapy program. There is no documentation that the enrollee requires an intensive rehabilitation therapy program, and there is concern that the enrollee will not be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility due to the enrollee's pain level. Care at the skilled nursing facility level appears to be appropriate 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 IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lumbar injections.
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the enrollee has not failed a recent 6-week trial of conservative treatment.
The Plan follows Medicare rules. Medicare rules say that facet joint interventions are only covered under certain medical indications. 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 requested services. Our physician reviewer found that the enrollee is status post an L3-L5 laminectomy for spinal stenosis. He is currently taking Celebrex. Physical therapy was ordered but there are no notes documenting completion or results. No other conservative therapy is documented. There is no documentation of conservative therapy post laminectomy. This does not meet the criteria and therefore, the request is deemed not medically reasonable and 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 the requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve lumbar injections.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the total electric hospital bed (E0265).
You asked the Plan to pre-approve the total electric hospital bed. You say that you would like reconsideration because the member will not be able to bend after surgery and their current bed is too high. The Plan denied your request. The Plan says this request is a convenience request for height adjustment and not reasonable or necessary.
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered. While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers coverage for this item. Therefore, we decided that the Plan does not have to pre-approve the total electric hospital bed (E0265).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve surgery to place Vertiflex Superion device (22869).

You asked the Plan to pre-approve Vertiflex Superion device. You say that it is your professional opinion based on clinical judgement, that the insertion of a lumbar interspinous spacer would provide significant clinical and quality of life benefits for the enrollee. The Plan denied your request. The Plan says this item is investigational and experimental, and the enrollee is not receiving this device as part of a Medicare covered clinical trial. More studies are needed to show Vertiflex is safe and effective.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The rules also say that experimental and investigational devices are not covered. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Vertiflex Superion device have not been met. Therefore, we decided that the Plan does not have to pre-approve surgery to place Vertiflex Superion device (22869).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral for services to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve these OON services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services can be provided by a 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 a referral for 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 complete maxillary denture (D5110) and a mandibular
partial denture (D5212).
You asked the Plan to pre-approve the complete maxillary denture and mandibular partial denture. You say that
you would like these services to be approved for coverage. The Plan denied your request. The Plan says these
services exceed the maximum counts allowed per period.
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, maxillary and mandibular complete
and partial dentures are limited to one procedure per arch every five plan years. The record shows that you
received a complete maxillary denture (D5110) and a mandibular partial denture (D5214) on January 28, 2020,
and your maxillary and mandibular denture benefits have been exhausted. Therefore, we decided that the Plan
does not have to pre-approve a complete maxillary denture (D5110) and a mandibular partial denture (D5212).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a total left knee arthroplasty to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that there are network providers available.

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 a total left knee arthroplasty to be provided by an out of network (OON) provider.