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

We decided that the Plan does not have to pre-approve Vertiflex surgery.
You asked the Plan to pre-approve Vertiflex surgery. You say that the requested Vertiflex device placement is medically necessary. The Plan denied your request. The Plan says Vertiflex surgery is considered experimental/investigational.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Vertiflex surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found The Vertiflex device is experimental. More research is needed to show safety and efficacy of the device before coverage will be approved. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Vertiflex surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve Vertiflex surgery.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide an additional 12 one-way non-emergent transportation trips.

You asked the Plan to provide the additional transportation. You say that you need additional trips to get to and from your doctor's appointments due to limited support from your relatives and a decline in your mobility. The Plan denied your request. The Plan says only the maximum 12 one-way trips as listed in the contract may be approved.

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. The Plan covers a maximum of 12 one-way trips per year. 

We looked at your request and the rules. Based on this information, we decided that you are requesting more trips than may be covered under the Plan's routine transportation benefit. Therefore, we decided that the Plan does not have to provide an additional 12 one-way non-emergent transportation trips.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an interspinous spacer device.
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says it has
not been shown to be safe and effective in long-term studies.
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 requested services. Our physician
reviewer found that the requested interspinous spacer device is experimental. More research is needed to show
safety and efficacy of the device. Therefore, the requested 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 requested services have not been met. Therefore, we decided that the Plan
does not have to pre-approve an interspinous spacer device.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.

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 admission is not medically necessary.

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 these services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you were admitted to the hospital with back pain and underwent lumbar spine surgery. You were then admitted to an inpatient rehabilitation facility (IRF) on April 28, 2021. The physical therapy notes state you need assistance with dressing, rolling, and sitting up. You have no documented skilled nursing or skilled therapy needs. You do not need skilled nursing or skilled therapy on a daily basis. As a practical matter, you do not require the necessary services on an inpatient basis at the SNF 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.
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 for the enrollee.
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee can safely receive the services needed, in other settings.
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. The enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require, or to be able to tolerate, fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at a lower level of care. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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 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 for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the consultation with an out-of-network provider.

You asked the Plan to pre-approve the consultation. You say that this doctor is the best optometrist in the area to provide proper care and resources. You say that the decision to deny your referral should be overturned. The Plan denied your request. The Plan says in-network providers are 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 the consultation with an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an electrical connection (E2310) for a power
wheelchair.

You asked the Plan to pre-approve the electrical connection. You say that this is medically necessary. The Plan
denied your request. The Plan says the electrical connection between the wheelchair controller and one motor
(E2310) cannot be covered.

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 electrical connection. Our reviewer
says that the requested electrical connection is not considered medically reasonable and necessary in this case.
Our physician reviewer found the enrollee is physically able to use the independent switches to control the
power tilt and elevated leg option therefore the requested expander is not 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 the electrical connection have not been met. Therefore, we decided that the Plan
does not have to pre-approve an electrical connection (E2310) for a power wheelchair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve four porcelain/ceramic crowns (D2740).
You asked the Plan to pre-approve the crowns. You say that these crowns are medically necessary. The Plan denied your request. The Plan says this type of crown is not covered by the Plan's supplemental dental benefit. In addition, only two crowns (D2750, D2751, D2752, D2753) may be covered in a calendar 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. 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 four porcelain/ceramic crowns (D2740).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies.

You asked the Plan to pre-approve incontinence supplies. You say that your medical skin condition only allows you to use wipes to shower. 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 incontinence supplies are not covered because they are hygienic items that are non-reusable. 

While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Intradialytic Parenternal Nutrition (IDPN).

You asked the Plan to pre-approve IDPN. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

The Plan follows Medicare rules. Medicare rules say that Parenternal Nutrition Therapy Daily parenteral nutrition is considered reasonable and necessary for a patient with severe pathology of the alimentary tract which does not allow absorption of sufficient nutrients to maintain weight and strength commensurate with the patient's general condition. 

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 IDPN. Our reviewer says that the services are not medically necessary. Our physician reviewer found the review indicates that you have a functioning gastrointestinal tract and is able to take nutrition orally. This is a request for three time a week parenteral nutrition in association with hemodialysis. Since parenteral nutrition is covered under the prosthetic device benefit and requires a nonfunctioning gastrointestinal tract for coverage, your condition does not meet the national coverage criteria. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IDPN have not been met. Therefore, we decided that the Plan does not have to pre-approve Intradialytic Parenternal Nutrition (IDPN).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the office visit with an out-of-network provider.
You asked the Plan to pre-approve the office visit. You say that you feel that you are in danger of having a heart attack. You say that there is a family history of heart failure and treatment has been customarily performed with this provider. The Plan denied your request. The Plan says in-network providers are 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 the office visit with an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the FreeStyle Libre continuous glucose monitor.
You asked the Plan to pre-approve the FreeStyle Libre continuous glucose monitor. You say that you would like reconsideration because this monitor is medically necessary. The Plan denied your request. The Plan says the documentation does not show that the member meets Medicare coverage criteria for the continuous glucose monitor.
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 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.
Based on this information, we decided that Medicare rules for coverage of the FreeStyle Libre continuous glucose monitor have not been met. Specifically, the documentation does not include any medical records to verify if Medicare coverage criteria have been met. Of note, the record indicates that the Plan made several attempts to obtain this information from your provider. Therefore, we decided that the Plan does not have to pre-approve the FreeStyle Libre continuous glucose monitor.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a partial upper denture with metal frame.
You asked the Plan to pre-approve the upper denture. You say that you need this denture to be approved for coverage. The Plan denied your request. The Plan says you have received all of the benefits for this specific 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, removable and fixed prostheses are limited to once every 60 months. The record shows that you received a partial denture on September 20, 2019 and your removable and fixed prosthesis benefit has been exhausted. Therefore, we decided that the Plan does not have to pre-approve a partial upper denture with metal frame.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve massage therapy.

You asked the Plan to pre-approve the massage therapy. The Plan denied your request. The Plan says naturopath services (uses natural or alternative treatments) is not covered under any condition. Massage therapy is considered a naturopathic service.

The Plan contract says that Naturopath services (uses natural or alternative treatments) are not covered under any condition.

The services at issue in this appeal are naturopathic services. Therefore, we decided that the Plan does not have to pre-approve massage therapy.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network pulmonologist.

You asked the Plan to pre-approve these services. You say that your cardiologist referred you to this provider
because they are close to you. The Plan denied your request. The Plan says the services are available from
network providers.

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. The network providers are located within
the Medicare-accepted distance from your home. 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 to an
out-of-network pulmonologist.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve upgraded electronics (E2311, E2313, E2377) for a power wheelchair.

You asked the Plan to pre-approve the accessories. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee's upper limb strength and function are adequate for the member to be able to control the power options using their own switches which are included in the allowance of these power options.

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 accessories. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the records indicate her upper extremity strength is 2+ to 3-/5 with left upper extremity coordination and control within functional limits. The only documented assistance she needs for feeding and bathing is a caregiver to cook for her and a shower chair for bathing. Her upper extremity strength and function appear to be adequate for her to be able to control the power options using their own switches.

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 accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve upgraded electronics (E2311, E2313, E2377) for a power wheelchair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics (L3225, L3010).

You asked the Plan to pre-approve foot orthotics. You say that the orthopedic shoes are medically necessary. The Plan denied your request. The Plan says this item is not a covered benefit.

Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. 

Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics (L3225, L3010).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Superion interspinous spacer.

You asked the Plan to pre-approve a Superion interspinous spacer. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a Superion interspinous spacer. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Superion device is experimental. More research is needed to show safety and efficacy of the device. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a Superion interspinous spacer have not been met. Therefore, we decided that the Plan does not have to pre-approve a Superion interspinous spacer.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a scooter (K0080).

You asked the Plan to pre-approve the scooter. You say that you would like reconsideration and for the Plan to purchase or help to facilitate the purchase of a scooter. The Plan denied your request. The Plan says your request is not medically necessary because your records show you routinely walk with the assistance of a walker while at home, you intend to use the power scooter outside your residence, and the face-to-face evaluation states a power scooter would exceed your needs.

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 scooter (K0080).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a fluid circulating cold pad with pump (E0218).

You asked the Plan to pre-approve the pad. You say that this is medically necessary. The Plan denied your
request. The Plan says this is not a covered benefit.

The Plan must follow Medicare rules. The rules say that a fluid circulating cold pad with pump (E0218) will be
denied as not reasonable and necessary.

The requested item is statutorily not covered by Medicare. Based on this information, we decided that
Medicare rules for coverage of the pad have not been met. Therefore, we decided that the Plan does not have to
pre-approve a fluid circulating cold pad with pump (E0218).