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

We decided that the Plan does not have to pre-approve a consultation an oral surgeon.
You asked the Plan to pre-approve the dental service. You say that you need to see an oral surgeon so that your
mouth can function. You say that you have already been to see your regular dentist. You say that it was
determined they cannot assist you so you were referred to an oral surgeon. You also say that you need this
service to be covered. The Plan denied your request. The Plan says dental services are only covered when you
receive them from a participating general dentist. The Plan also says that services performed by an oral surgeon
are not covered.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a
consultation an oral surgeon.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approvemaxillary partial denture -cast metal framework with resin denture bases (D5213).You asked the Plan to pre-approvemaxillary partial denture -cast metal framework with resin denture bases. You say that the service is medically necessary.The Plan denied your request. The Plan says that the frequency limit has been met for this 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. The Plan covers maxillary partial denture -cast metal framework with resin denture bases once every three years. We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of maxillary partial denture -cast metal framework with resin denture bases have been met. Specifically, the record shows that you last received a partial denture on August 7, 2017. This means that more than 3 years has gone by and the frequency limitation is not exhausted at this time. Therefore, we decided that the Plan has to pre-approvemaxillary partial denture -cast metal framework with resin denture bases (D5213).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 toopen the case again, we will send you a letter.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Eucrisa.

You asked the Plan to pre-approve Eucrisa. You say that this medication is medically necessary. The Plan
denied your request. The Plan says Eucrisa 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 Eucrisa.

Benefits for Eucrisa 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 Plandoes not haveto pre-approvecompression stockings identified with code A4465.You asked the Planto pre-approvethe compression stockings. You say that this is medically necessary.The Plandenied your request. The Plansaysthis is not a Medicare-covered benefit.The Plan must follow Medicare rules. The rules say that compression stockings described by code A4465 are noncovered because they do not meet the statutory definition of a surgical dressing. Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan.Therefore, we decided that the Plandoes not haveto pre-approvecompression stockings identified with code A4465.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea consultation and extractions to be provided by an oral surgeon.You asked the Plan to pre-approvethe dental services. You say that you have recently cracked a molar. You say that you are on a liquid diet because the pain is preventing you from eating food. You also say that you were referred to an oral surgeon by your regular dentist.The Plan denied your request. The Plan says dental services are covered when they are performed by a participating general dentist. The Plan also says that dental services performed by an oral surgeon are not covered.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit when performed by an oral surgeon.Therefore, we decided that the Plan does not have to pre-approvea consultation and extractions to be provided by an oral surgeon.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve amniotic stem cell injections for the knee.
You asked the Plan to pre-approve amniotic stem cell injections. You say that you have exhausted all
conservative efforts to avoid knee surgery. The Plan denied your request. The Plan says this service is not
medically necessary for your condition.
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 amniotic stem cell injections. Our
reviewer says that the requested items/services are not considered medically reasonable and necessary in this
case. Our physician reviewer found current evidence based medical peer reviewed literature indicate that stem
cell therapy remains investigational for the treatment of knee osteoarthritis and knee cartilage regeneration.
Therefore, the request for stem cell therapy would not be considered medically reasonable and necessary at this
time as the safety and effectiveness has not been fully established.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of amniotic stem cell injections have not been met. Therefore, we decided that the
Plan does not have to pre-approve amniotic stem cell injections for the knee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to providea pneumatic compression device (E0652).You asked the Plan to providea pneumatic compression device. You say that the basic pump does not treat truncal swelling.The Plan denied your request. The Plan says there are not pre and post measurements over 4 weeks to support a good faith trial with the basic pump.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 providea pneumatic compression device (E0652).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea consultation and root canal to be provided by an endodontist.You asked the Plan to pre-approvethe dental services. You say that you need a root canal. You also say that you are in a lot of pain.The Plan denied your request. The Plan says dental services are only covered when they are performed by a participating general dentist. The Plan says that dental services performed by an endodontist are not covered. The Plan also says that there is no benefit for a root canal.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-approvea consultation and root canal to be provided by an endodontist.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve percutaneous laminotomy.
You asked the Plan to pre-approve the surgery. 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. Medicare rules say that percutaneous image-guided lumbar
decompression is only covered when part of an approved clinical study.
There is no evidence of an approved clinical study. Based on this information, we decided that Medicare rules
for coverage of the surgery have not been met. Therefore, we decided that the Plan does not have to preapprove
percutaneous laminotomy.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a partial upper denture with a flexible base (D5225) and
core build up (D2950).
You asked the Plan to pre-approve the dental services. You say that the enrollee needs these services. The Plan
denied your request. The Plan says the partial upper denture with a flexible base is not listed as a covered
service. The Plan also says that core build up is not listed as a covered service.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. The Customer Handbook clearly states that if a dental item or service
is not listed in the benefit chart or listed with NC, then it is not covered. Therefore, we decided that the Plan
does not have to pre-approve a partial upper denture with a flexible base (D5225) and core build up (D2950).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea personal emergency response system.You asked the Planto pre-approvethe system. You say that this is medically necessary.The Plandenied your request. The Plansaysthis is not covered by Medicare.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 Plandoes not haveto pre-approvea personal emergency response system.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea CT scan of the heart with evaluation of blood vessel calcium.You asked the Plan to pre-approvea CT scan of the heart with evaluation of blood vessel calcium. 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 follows Medicare rules. Medicare rules say that CT scan of the heart with evaluation of blood vessel calcium is only covered for certain indications.We asked our physicianreviewer 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 CT scan of the heart with evaluation of blood vessel calcium. Our reviewer says that the documentation does not support that the requested services are medically reasonable or necessary. Our physician reviewer found you are intermediate risk for Coronary Artery Disease (CAD) but a relatively high low-density lipoprotein and guidelines do suggest that CT calcium scoring can be used as an adjunct to decision making about starting statin therapy in some intermediate risk situations. CMS rules however, do not consider isolated quantitative calcium scoring (in the absence of a clinical need for CT coronary angiography) a covered service as it is considered a screening examination. Therefore, you do 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 CT scan of the heart with evaluation of blood vessel calcium have not been met. Therefore, we decided that the Plan does not have to pre-approvea CT scan of the heart with evaluation of blood vessel calcium.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Dupixent 300/2ml injections.
You asked the Plan to pre-approve Dupixent. You say that Dupixent 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 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 Dupixent 300/2ml injections.
Benefits for Dupixent 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve aquatic therapy to be provided by the out-of-network
provider.
You asked the Plan to pre-approve the aquatic therapy. The Plan denied your request. The Plan says the Plan
requires the enrollee to receive care from providers who are part of the enrollee's primary care physician's
(PCP) specialty 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 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 aquatic
therapy to be provided by the out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea complete upper denture (D5110) and a complete lower denture (D5120).You asked the Plan to pre-approvethe dental items. You say that the enrollee needs dentures. You say that the enrollee has no teeth. You also say that the enrollee has cancer and needs to eat.The Plan denied your request. The Plan says dentures are not a covered service.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approvea complete upper denture (D5110) and a complete lower denture (D5120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two gingival irrigations (D4921 x2).

You asked the Plan to pre-approve the gingival irrigations. The Plan denied your request. The Plan says this
service is not covered under your benefit package.

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 two
gingival irrigations (D4921 x2).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation of the facet joints.

You asked the Plan to pre-approve radiofrequency ablation of the facet joints. You say that this service is medically necessary for treatment of pain. The Plan denied your request. The Plan says there has not been three months of pain relief.

The Plan follows Medicare rules. The rules state that the thermal radiofrequency destruction of cervical, thoracic or lumbar paravertebral facet joint (median branch) nerves will be considered to be medically reasonable and necessary after the patient has had at least 2 medically reasonable and necessary diagnostic MBBs, with each one providing a minimum of 80% relief of primary (index) pain (with the duration of relief being consistent with the agent used) or at least 50% improvement in the ability to perform previously painful movements and ADLs.

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 radiofrequency ablation of the facet joints. Our reviewer says that radiofrequency ablation of the facet joints is not medically necessary at this time.

Our physician reviewer found the clinical documentation does not support that you had at least two medically reasonable and necessary diagnostic MBBs, with each one providing a minimum of 80% relief of primary (index) pain (with the duration of relief being consistent with the agent used) or at least 50% improvement in the ability to perform previously painful movements and ADLs; OR after you had at least one medically reasonable and necessary therapeutic injection that provided at least 50% pain relief for three months. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of radiofrequency ablation of the facet joints have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation of the facet joints.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve continued skilled nursing facility (SNF) services.

You asked the Plan to pre-approve SNF care. You say that you continue to need wound care and therapy. The
Plan denied your request. The Plan says that the records fail to show progression.

The Plan must follow Medicare Rules. The rules say that Medicare plans must tell an enrollee that the Plan will
stop paying for skilled nursing facility services. The Plan must issue a NOMNC no later than two days before
the last covered day. This notice must include a description of the enrollee's right to an appeal.

We looked at the file and the Medicare rules. The file does not show that a valid NOMNC was delivered two or
more days before the last covered day of SNF Services. The Plan must pay for SNF services until the 100-day
SNF care benefit is exhausted or daily skilled care is no longer needed and proper notice is issued. Therefore,
we decided that the Plan has to pre-approve continued skilled nursing facility (SNF) services.

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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea surgical placement of an implant body: endosteal implant (D6010).You asked the Plan to pre-approvethe endosteal implant. The Plan denied your request. The Plansays this service is not covered.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approvea surgical placement of an implant body: endosteal implant (D6010).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the seat lift mechanism of a seat lift chair.

You asked the Plan to pre-approve the seat lift mechanism of a seat lift chair. You say that you need a lift chair
because you cannot stand or put weight on your leg. The Plan denied your request. The Plan says you do not
have a documented diagnosis of neuromuscular disease or severe arthritis of the hip or knee.

The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions
listed above are met. Medicare does not cover the upholstered portion of a seat lift chair.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the seat lift mechanism of a seat lift chair have not been met. Therefore, we decided that the Plan
does not have to pre-approve the seat lift mechanism of a seat lift chair.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approveVertiflex spacer system.You asked the Plan to pre-approveVertiflex spacer system. 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 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 spacer system. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has chronic low back pain from spinal stenosis causing leg and back pain. The requested device is considered experimental. More research is needed to show safety and efficacy. 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 Vertiflex spacer system have not been met.Therefore, we decided that the Plan does not have to pre-approveVertiflex spacer system.