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

We decided that the Plan does not have to pre-approvea maxillary interim partial denture (D5820) and mandibular interim partial denture (D5821).You asked the Plan to pre-approvethe maxillary and mandibular interim partial dentures. The Plan denied your request. The Plan says these services are not covered under the enrollee's 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-approvea maxillary interim partial denture (D5820) and mandibular interim partial denture (D5821)
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair (E2359, E2311, K0861, E1007).
You asked the Plan to pre-approve the power wheelchair. You say that the power chair is medically necessary.
The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not
have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.
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 power wheelchair. Our reviewer
says that the requested powered mobility device is not medically necessary. Our physician reviewer found there
is no documentation that the requested power mobility device is medically necessary. The available records
indicate the enrollee is extremely weak and unable to sit unsupported and that she is only able to move her
hands. Records do not clearly indicate that the enrollee has had a trial using the requested power wheelchair
and demonstrated the ability to safely use it.
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 power wheelchair have not been met. Therefore, we decided that the Plan
does not have to pre-approve a power wheelchair (E2359, E2311, K0861, E1007).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Methylphenidate 20mg ER tablet medication. 
 
You asked the Plan to pre-approve this medication. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says this medication is not a covered benefit under the 
member's contractual policy. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drug requested here is not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve the Methylphenidate 20mg 
ER tablet medication.  
 
Benefits for this medication 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspiration for the enrollee. 
 
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 the clinical value and effectiveness of bone marrow aspirate in the 
setting of spinal fusion surgery has not been demonstrated in the peer-reviewed literature. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Bone marrow 
aspirate remains experimental for use in spine fusion surgery. More research is needed to show safety and 
efficacy. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for these 
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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve bone marrow aspiration for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approveextractions (D7140).You asked the Plan to pre-approvethe dental services. You say that you need to have teeth extracted. You say that they are causing infections. You say that you are sick all of the time. You say that you were on antibiotics and have been for a long time.  You also say that they do not work as good anymore.The Plan denied your request. The Plan says the extractions are dentalin nature. The Plan also says extractions are not listed as a covered service.Medicare generally does not cover dental services. The Plan follows the same rule.The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Additionally, although the Plan offers a dental benefit in excess of Medicarecoverage, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approveextractions (D7140)
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a prefabricated abutment (D6057) and an abutment 
supported crown (D6058) for tooth # 19. 
 
You asked the Plan to pre-approve the dental services. You say that you were planning to have these services 
done while you still had some coverage under your husband's dental policy. You say that your husband lost his 
job due to Covid-19. You also say that you were not able to receive this treatment before the event occurred. 
The Plan denied your request. The Plan says tooth # 19 was missing prior to the enrollee's eligibility under this 
plan. The Plan says implant services to replace a tooth that was missing prior to the effective date of coverage. 
The Plan also says that this exclusion will not apply if the enrollee has had continuous coverage under that plan 
for 24 months. 
 
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, implant related services to replace a 
tooth or teeth extracted prior to your effective date are not covered under this benefit. The record shows that 
you had tooth # 19 extracted on October 18, 2019, before you were active with your current plan. Therefore, 
we decided that the Plan does not have to pre-approve a prefabricated abutment (D6057) and an abutment 
supported crown (D6058) for tooth # 19.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveSNF care to be provided to the enrollee.You asked the Plan to pre-approveSNF care. You say that the stay is medically necessary.The Plandenied your request. The Plan says the stay 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 above 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found based on the documentation provided, the enrollee does not qualify for SNF coverage. The enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. The enrolleeappears to be unable to tolerate daily skilled therapy. 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 (ex. intermittent skilled therapy, restorative nursing therapy, LTC).We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met.Therefore, we decided that the Plan does not have to pre-approveSNF care to be provided to the enrollee
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe medical services to be provided by an out of network (OON) provider.You asked the Plan to pre-approveoffice visit. You say that you have been seeing this provider for over 15 years and want to continue.The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this provider is out-of-network with the Plan and you can be treated by an in-network neurologist.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. No continuity of care issue has been identified in this case. 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-approvethe medical services to be provided by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transfer to LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. 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 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 still requires acute hospital level of care services and is receiving appropriate care at the present acute 
care hospital. The enrollee does not require services at the LTACH that are not available at the acute care 
hospital where they are currently receiving care. There are no services available at the LTACH that the enrollee 
requires that are not available at the health care setting being offered by the health plan. The requested LTACH 
services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee 
and able to be furnished safely and effectively only on an inpatient basis. 
 
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 transfer to LTACH services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvejaw surgery for the enrollee.You asked the Plan to pre-approvejaw surgery. You say that these services are medically necessary.The Plan denied your request. The Plan says that this is not a covered benefit.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.The services you are asking the Plan to pre-approve involve the treatment of your teeth and the structures directly supporting your teeth. Although there may be medical concerns related to this requested procedure, the procedure itself falls within the definition of dental care which is excluded from Medicare coverage. 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-approvejaw surgery for the enrollee
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approveurology services to be provided by an out of network provider.You asked the Plan to pre-approvethe urology services. You say that you do not want to be treated at your current doctor's office.The Plan denied your request. The Plan says your condition can be managed at a lower level of care.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-approveurology services to be provided by an out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device. 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the requested device is not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a pneumatic compression device is only covered for 
certain 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 a pneumatic compression device. Our 
reviewer says that the documentation does not support that the requested pneumatic compression device is 
medically reasonable or necessary. Our physician reviewer found you were diagnosed with neuralgia and 
radiculopathy. The documentation does not support that your lymphedema is then documented to be 
unresponsive to other clinical treatment over the course of a required four-week trial. Therefore, you do not 
meet criteria for the requested 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 pneumatic compression device have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a pneumatic compression device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair. 
 
You asked the Plan to pre-approve a shower chair. You say that this should be paid for. The Plan denied your 
request. The Plan says this is not a Medicare covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
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. 
 
You asked the Plan to pre-approve IRF care. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the requested admission 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 above. 
 
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 you were admitted to the hospital for nausea, vomiting and a COVID-19 infection. 
Your medical conditions are stable. The documentation does not support that you require an acute hospital 
inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not support that 
you require an intensive rehabilitation program. 
 
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.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. 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 IRF admission is covered only when it is medically reasonable and necessary as described above.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 medically necessary. Our physician reviewer found the enrollee was admitted to the hospital on January 22, 2021 with bacteremia and sacral wounds. The physical therapy note states she needs maximal assist with bed rolling, sitting up, and lying down. The enrollee does not require the intensity of services in an IRF. Specifically, she is not shown to be able to tolerate 15 hours per week of rehabilitative services and regular physician evaluation. The IRF services 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 IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plandoes not haveto pay forambulance services (A0429-QL) provided to the enrollee on April 6, 2020.You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The Plansaysthe claim was not billed according to CMS guidelines.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the ambulance services (A0429-QL) have not been met. Specifically, code A0429 is not the appropriate code for billing Medicare when the enrollee is pronounced dead after the ambulance is called. Medicare requires the reporting of A0428 for services provided under these circumstances. Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plandoes not haveto pay forambulance services (A0429-QL) provided to the enrollee on April 6, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the
enrollee.
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary.
The Plan denied your request. The Plan says that the enrollee's medical needs are being met in the current acute
setting.
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. Long term
acute care hospitals are certified as acute care hospitals, and in general, LTACHs do not provide clinical
services that are materially different than those of short term acute care hospitals. The enrollee is receiving
acute hospital care, and acute care services have not been denied. The documentation does not support that the
enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is
currently receiving care. Our physician reviewer found that the enrollee's condition does not meet Medicare
criteria for LTACH 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 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 for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve HBOT (CPT Code 99183). 
 
You asked the Plan to pre-approve the HBOT. You say that the services are necessary. The Plan denied your 
request. The Plan says this diagnosis is not an indication for this treatment. The Plan must follow Medicare 
rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the HBOT have not been met. The enrollee has had frequent bladder infections causing ulcers 
inside their bladder. The enrollee tried other treatments that did not work. Medicare covers HBOT for a number 
of conditions including gangrene, certain skin grafts and certain diabetic wounds that have failed other 
treatments. The enrollee's diagnosis is not included in the indications that Medicare covers. Therefore, we 
decided that the Plan does not have to pre-approve HBOT (CPT Code 99183).