Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Favorable

We decided that the Plan has to pre-approve additional physical therapy visits.
You asked the Plan to pre-approve additional visits. You say that therapy will help the enrollee's Achilles tendon improve. The Plan denied your request. The Plan says that the enrollee has not made significant improvement.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. The file shows that 10 additional visits were requested. 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 visits. Our physician reviewer found that you have left ankle pain related to Achilles tendinitis. You have been receiving outpatient physical therapy treatment for pain and difficulty with activities. The requested therapy is generally accepted as specific and effective therapy for your condition. There is documentation that the unique skills of a professional therapist are required to safely and effectively provide treatment. You have had an improvement in your Lower Extremity Functional Scale from 20/80 to 33/80 with therapy. Further skilled therapy at this point does appear to be likely to achieve further improvement in the patient's symptoms and/or functional status. 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 visits have been met. Therefore, we decided that the Plan has to pre-approve additional physical therapy visits.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for tumor immunohistochemistry morphometric analysis (88361) provided on November 12, 2020.
You asked the Plan to pay for tumor immunohistochemistry morphometric analysis. You say that this should be covered. The Plan denied your request. The Plan says this was 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 pay for tumor immunohistochemistry morphometric analysis. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the American Society of Gastrointestinal Endoscopy has given WATS-3D technology a conditional rating for individuals with known or suspected Barrett's esophagus based upon low level evidence. In this case, the enrollee has gastroesophageal reflux without esophagitis. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of tumor immunohistochemistry morphometric analysis have not been met. Therefore, we decided that the Plan does not have to pay for tumor immunohistochemistry morphometric analysis (88361) provided on November 12, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ground mileage (A0425) and non-emergent ambulance transport (A0428) provided on January 27, 2021.
You asked the Plan to pay for the ground mileage and non-emergent ambulance transport. You say that you would like these services to be reconsidered for coverage. The Plan denied your request. The Plan says ambulance transport to or from an outpatient office or facility is not a Medicare covered benefit.
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. 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 pay for the ground mileage and non-emergent ambulance transport. Our reviewer says that the ground mileage and non-emergent ambulance transport do not meet coverage criteria. Our physician reviewer found the enrollee required transportation for Shingrix vaccination. Our reviewer found that the provided records are insufficient to determine the medical necessity of the ambulance transportation, as opposed to another modality such as stretcher van, for the enrollee. Our physician reviewer also found that the elements of the coverage rule are not satisfied. The requested service cannot be recommended. 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 ground mileage and non-emergent ambulance transport have not been met. Therefore, we decided that the Plan does not have to pay for the ground mileage (A0425) and non-emergent ambulance transport (A0428) provided on January 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve routine eyewear to be provided by a non-Plan vendor.

You asked the Plan to pre-approve routine eyewear to be provided by a non-Plan vendor. You say that you are unhappy with the Plan's eyeglasses. The Plan denied your request. The Plan says the vision allowance is to be used at a Plan optical facility when a physician or optometrist prescribes eyeglasses or contact lens for vision correction.

Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when provided from a Plan optical facility.

We looked at the file and the Plan's rules. The file shows that the Plan's vision allowance is to be used at a Plan optical facility. Therefore, we decided that the Plan does not have to pre-approve routine eyewear to be provided by a non-Plan vendor.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a partial upper denture (D5213) and a partial lower denture (D5214).
You asked the Plan to pre-approve the dental services. You say that the enrollee has lost her set of partial dentures. You say that the enrollee is not able to eat and has lost weight due to having any teeth. You also say that new partials are medically necessary. The Plan denied your request. The Plan says dentures are covered once every 5 plan years. The Plan also says that the frequency limit has been reached.
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 and partial dentures are listed as covered, the frequency limit has been reached. The record shows that the Plan paid for dentures that you received on July 26, 2018. Therefore, we decided that the Plan does not have to pre-approve a partial upper denture (D5213) and a partial lower denture (D5214).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion of an interlaminar/interspinous process
stabilization/distraction device.
You asked the Plan to pre-approve insertion of an interlaminar/interspinous process stabilization/distraction
device. 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 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 insertion of an interlaminar/interspinous
process stabilization/distraction device. Our reviewer says that the requested items/services are not considered
medically reasonable and necessary in this case. Our physician reviewer found there is no compelling rationale
presented or extenuating circumstances noted to support the medical necessity of this request as an exception to
guidelines. Therefore, the request for Vertiflex Superion interlaminar/interspinous process
stabilization/distraction device at L3-L4 and L4-L5 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 insertion of an interlaminar/interspinous process stabilization/distraction device
have not been met. Therefore, we decided that the Plan does not have to pre-approve insertion of an
interlaminar/interspinous process stabilization/distraction device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an implant supported porcelain/ceramic crown (D6065)
for tooth 8.

You asked the Plan to pre-approve an implant supported crown. You say that the service is necessary for your
personal image and ability to eat. The Plan denied your request. The Plan says this service is not covered under
your dental 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 an
implant supported porcelain/ceramic crown (D6065) for tooth 8.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve direct skilled nursing services of a registered nurse (RN)
in the home health or hospice setting (G0299).
You asked the Plan to pre-approve the skilled nursing services. You say that the medical records provided
support the necessity of the services in dispute. The Plan denied your request. The Plan says the enrollee does
not meet the medically necessary criteria for the continued home health aide services, however the plan
approved for HHA services for 30 days to ease the transition to more appropriate covered services.
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically
necessary for the enrollee to receive skilled nursing or 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 the skilled nursing services. Our
reviewer says that the requested items/services are not considered medically reasonable and necessary in this
case. Our physician reviewer found direct skilled nursing services of a registered nurse (RN) in the home health
or hospice setting (G0299) is not medically necessary as the records do not show that skilled nursing services
are required to effectively provide treatment, care, and/or services in order to improve the enrollee's condition,
or to establish/perform a maintenance program to maintain the enrollee's condition and/or prevent
deterioration. The records do not reveal complex wound care, new enteral feedings or other complex SN need
therefore this request 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 skilled nursing services have not been met. Therefore, we decided that the
Plan does not have to pre-approve direct skilled nursing services of a registered nurse (RN) in the home health
or hospice setting (G0299).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Bevespi Aerosphere inhaler.
You asked the Plan to pre-approve the Bevespi Aerosphere inhaler. You say that the enrollee is intolerant to
Trelegy and Anoro. The Plan denied your request. The Plan says this drug is not covered for the enrollee's
condition by Medicare Part B.
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 a Bevespi Aerosphere
inhaler.
Benefits for the Bevespi Aerosphere 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: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Procrit (J0885).You asked the Plan to pre-approve Procrit. You say that this is medically necessary.The Plan denied your request. The Plan says step therapy requirements have not been met.Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications.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 Procrit. Our reviewer says that the requirements for coverage of Procrit have not been met. Our physician reviewer found the Plan requires a trial of Retacrit before they will approve the requested drug. The patient has not tried and failed the required drug and there is no documentation provided indicating that the Plan's required drug would likely be less effective or have adverse effects.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Procrit have not been met.Therefore, we decided that the Plan does not have to pre-approve Procrit (J0885).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan.
You asked the Plan to pre-approve a PET scan. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that PET 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 a PET scan. Our reviewer says that the documentation does not support that the requested services are medically reasonable or encessary. Our physician reviewer found the enrollee has a new diagnosis prostate cancer. A PET scan is indicated for enrollees with rising prostate-specific antigen (PSA) after definitive treatment. It is not indicated for initial staging. Therefore, the enrollee does not meet criteria for the requested services. 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 PET scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a powered upper extremity range of motion assist
device (L8702).

You asked the Plan to pre-approve this item. You say that this item is medically necessary. The Plan denied
your request. The Plan says this item 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 this item. Our reviewer says that the
requested item is not considered medically reasonable and necessary in this case.

Our physician reviewer found that according to Medicare an item is medically reasonable and necessary if it is
safe and effective and not mainly for the convenience of the patient or the physician. In order to be considered
medically necessary an item cannot be investigational or experimental and must be ordered by qualified
personnel and be appropriate to the patient's medical needs and condition. Additionally, there must be an
appropriate duration and frequency that is considered appropriate for the item.

In this case, the documentation supports that the requested treatment is considered investigational or
experimental. You have had right-sided weakness for a long-term period of time after having a stroke in 2014.
The requested treatment with a powered upper extremity range of motion assist device 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 this item have not been met. Therefore, we decided that the Plan does not have
to pre-approve a powered upper extremity range of motion assist device (L8702).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from August 7, 2020, to September 5, 2020.
You asked the Plan to pay for the SNF services. You say that the services are coverable under the Medicare Act. The Plan denied your request. The Plan says that daily skilled services were not provided during the dates of service in this case.
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 pay for the SNF services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from August 7, 2020, to September 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on January 23, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
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 had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. 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 the services provided by an out-of-network provider on January 23, 2021.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pay for air ambulance transportation (A0431), and air mileage (A0436) provided on December 10, 2020.
You asked the Plan to pay for air ambulance transportation, and air mileage. You say that the services were medically necessary. The Plan denied your request. The Plan says that criteria for air ambulance transportation was not met.
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your medical condition is such that transportation by ground ambulance is not appropriate. 
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 pay for air ambulance transportation, and air mileage. Our reviewer says that the elements of the coverage criteria are satisfied. Our physician reviewer found the enrollee was transported 109. The record indicates that multiple hospitals, including facilities closer to the pickup point location were contacted, and refused the enrollee. The enrollee required care at a higher-level facility. Ground transportation was contraindicated. 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of air ambulance transportation, and air mileage have been met. Therefore, we decided that the Plan has to pay for air ambulance transportation (A0431), and air mileage (A0436) provided on December 10, 2020.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the office visit related to a custom oral sleep appliance
to be provided by an OON provider.
You asked the Plan to pre-approve the office visit related to a custom oral sleep appliance. You say that this
provider is the best in the area, and you do not want to go to another provider. The Plan denied your request.
The Plan says the provider is out-of-network
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 related to the custom oral sleep appliance to be provided by an OON provider.