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

We decided that the Plan does not have to pre-approve the rebase complete maxillary denture (D5710), the
base mandibular partial denture (D5721), or the periodontal scaling and root planing (D4342).
You asked the Plan to pre-approve the rebase complete maxillary denture (D5710), the rebase mandibular
partial denture (D5721), and the periodontal scaling and root planing (D4342). You say that the member is in
pain and needs extractions as well as complete upper denture and lower partial denture. The Plan denied your
request. The Plan says the services are not covered 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 rebase complete maxillary denture
(D5710), the rebase mandibular partial denture (D5721), and the periodontal scaling and root planing (D4342)
are not among those covered under this benefit. Therefore, we decided that the Plan does not have to preapprove
the rebase complete maxillary denture (D5710), the rebase mandibular partial denture (D5721), and
the periodontal scaling and root planing (D4342).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet injections (64490, 64491, and 64492).
You asked the Plan to pre-approve facet injections (64490, 64491, and 64492). You say that the requested facet
injections are medically necessary. The Plan denied your request. The Plan says the requested facet injections
do not meet criteria.
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 facet injections (64490, 64491, and
64492). Our reviewer says that the requested facet injections do not meet criteria. Our physician reviewer
found the enrollee is diagnosed with other cervical disc displacement, unspecified cervical region. Cervical
facet injections are not indicated at this time. More conservative treatment is needed. There is no
documentation of a recent and adequate trial of physical therapy for neck pain.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of facet injections (64490, 64491, and 64492) have not been met. Therefore, we
decided that the Plan does not have to pre-approve facet injections (64490, 64491, and 64492).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to providean ultralight wheelchair with power assist.You asked the Plan to providean ultralight wheelchair with power assist. You say that an ultra-lightweightmanual wheelchair with smart drive power assist is the best option for transporting and community use.The Plan denied your request. The Plan says the enrollee has a progressive condition and a power wheelchair is more appropriate.The Plan follows Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.The evaluation shows a Group 3 power wheelchair is more appropriate for the enrollee's medical needs.Therefore, we decided that the Plan does not have to providean ultralight wheelchair with power assist.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 1 power operated vehicle and accessories.You asked the Plan to pre-approve a Group 1 power operated vehicle and accessories. You say that you have back pain and weakness of the legs.The Plan denied your request. The Plan says the record shows you are able to use a walker and scooters are not provided for community mobility.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. The file shows that you do not have a mobility deficit that impairs your participation in MRADLs and your condition can be improved by a walker, cane or manual wheelchair. Also, the item at issue in this appeal is being requested for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan cover PMDs for use only outside the home. This means that Medicare rules for coverage of a PMD have not been met.Therefore, we decided that the Plan does not have to pre-approve a Group 1 power operated vehicle and accessories.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approveBioWave percutaneous electrical nerve stimulation (PENS).You asked the Plan to pre-approvethese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are not covered.The Plan must follow Medicare rules. Medicare rules say that the BioWave device is not covered.We looked at the file and Medicare rules. The services at issue are BioWave PENS described by code 64999. These services are not covered by Medicare.Therefore, we decided that the Plan does not have to pre-approveBioWave percutaneous electrical nerve stimulation (PENS).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 2 custom fabricated abutment (D6057) and 2 abutment supported porcelain fused to metal crown (D6059).
You asked the Plan to pre-approve the dental services. You say that you started your implant procedure in September 2019. You say that it was approved, but not finished. You say that you would like to finish the implant procedure. The Plan denied your request. The Plan says the custom fabricated abutments and abutment supported crowns are not listed as covered services.
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 dental services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 2 custom fabricated abutment (D6057) and 2 abutment supported porcelain fused to metal crown (D6059).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a diagnostic esophagogastroduodenoscopy (43235).
You asked the Plan to pre-approve a diagnostic esophagogastroduodenoscopy. You say that you need this to
see if your problems are resolving. The Plan denied your request. The Plan says a repeat endoscopy is not
necessary.
The Plan follows Medicare rules. Medicare rules say that sequential or periodic diagnostic upper GI endoscopy
may be indicated for an appropriate number of procedures for active or symptomatic conditions per the above
listed guidelines.
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 diagnostic
esophagogastroduodenoscopy. Our reviewer says that the requested service is not medically necessary at this
time. Our physician reviewer found you do not report gastroesophageal reflux disease symptoms. Your review
of systems on page proved negative for heartburn and dysphagia. You also have no histologic evidence of
esophagitis of any grade. Per the provided pathology report, both proximal and distal esophageal biopsies
revealed only reflux-like changes in reactive squamous mucosa. Reactive change without advanced esophagitis
does not constitute by standard-of-care an appropriate indication to check healing by repeat
esophagogastroduodenoscopy.
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 diagnostic esophagogastroduodenoscopy have not been met. Therefore, we
decided that the Plan does not have to pre-approve a diagnostic esophagogastroduodenoscopy (43235).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forthe acute inpatient hospital care provided from July 27, 2019 through July 28, 2019.You asked the Plan to pay foracute inpatient hospital care. You say that the stay was 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 inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the review has determined that the record did not show that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergency department (ED) and/or observation care) would span two midnights.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met.Therefore, we decided that the Plan does not have to pay forthe acute inpatient hospital care provided from July 27, 2019 through July 28, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on October 15, 2019.
You asked the Plan to waive the copayment for the ambulance transport. The Plan denied your request. The Plan says that the correct copayment was applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $200 copayment for each one-way Medicare-covered ambulance transport. You have been asked to pay a $200 copayment for the ambulance transport. The ambulance transport falls within the one-way Medicare-covered ambulance transport benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the ambulance transport provided on October 15, 2019.
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 the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.
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 admission to an IRF does not meet criteria. Our physician reviewer found the enrollee was admitted and medically/surgically managed in the acute care hospital. He has been provided with acute therapy and has progressed very slowly. The enrollee has a PEG placed on 03/18. A 03/18 Neuro assessment showed the enrollee was alert and oriented x 3, memory intact, and behavior appropriate to situation. A physical medicine and rehab evaluation recommends Inpatient Rehabilitation. Current level of function is dependent for bed mobility, bathing, and dressing. He is moderate assist for grooming. Ambulation was not tested. He is lethargic. Prior to admission, the enrollee was independent for mobility and activities of daily living. The complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that the enrollee's medical status requires the intensity of an IRF stay with close physician or nursing supervision. The enrollee may benefit and participate in additional therapy of physical therapy and occupational therapy but the enrollee's functional level does not require this on an intensive rehabilitation facility therapy program level in an IRF. 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve admission to a skilled nursing facility (SNF). You say that the requested admission to a SNF is medically necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet criteria.
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 admission to a skilled nursing facility (SNF). Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to the hospital with a fall and head laceration. From a nursing perspective, there are no nursing notes to document skilled services. Regarding rehabilitation services, the enrollee received physical therapy, speech therapy and occupational therapy. The enrollee required supervision/touch assist to moderate assist with functional mobility including gait to 50-99 feet. The enrollee required varying assist with activities of daily living. She had moderate memory impairment. There are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. This enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 admission to a skilled nursing facility (SNF) have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
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 you have urinary incontinence and you have been purchasing diapers for it. You say that you need the requested diapers and have been waiting for a while.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 the telephone alert system.
You asked the Plan to pre-approve the telephone alert system. You say that you have a brain injury and is on seizure medication so you are a fall risk and feel that this should be covered. The Plan denied your request. The Plan says telephone alert systems are specifically excluded from coverage because they are emergency communications systems.
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 Plan does not have to pre-approve the telephone alert system.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the LINX procedure (CPT 43284) for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says this is statutorily excluded from CMS coverage.
The Plan must follow Medicare rules. The rules say that CPT 43284 is not a covered code. The requested procedure is coded with CPT 43284. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pre-approve the LINX procedure (CPT 43284) for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea laminotomy for the enrollee.You asked the Plan to pre-approvethese services. You say that the servicesare medically necessary.The Plan denied your request. The Plan says the services are not medically necessary.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary.Our physician reviewer found the enrollee has lumbar radiculopathy. There is no documentation of an adequate trial and failure of conservative measures. More conservative measures, such as physical therapy, are needed. The requested surgery is not reasonable or medically necessary at this time.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pre-approvea laminotomy for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a new patient chiropractic office visit. You asked the Plan to pre-approve the visit. You say that this is medically necessary. The Plan denied your request. The Plan says this is not manual manipulation of the spine to correct subluxation. The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pre-approve a new patient chiropractic office visit.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Reclast
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 that the services are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are medically necessary. Our physician reviewer found the enrollee has age-related osteoporosis with fracture. Reclast is a once-yearly intravenous infusion approved for the treatment of osteoporosis in men, in postmenopausal women, and in patients with glucocorticoid-induced osteoporosis and is the most potent bisphosphonate available. The records support that Reclast is safe and effective and reasonable and medically necessary for the enrollee at this time. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have been met. Therefore, we decided that the Plan has to pre-approve Reclast
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genicular nerve injection to the knee for the enrollee.You asked the Plan to pre-approve the injection. You say that this is medically necessary.The Plan denied your request. The Plan says this procedure is considered experimental and 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 the injection. Our reviewer says that the requested injection is not considered medically reasonable and necessary in this case. Our physician reviewer found this is an experimental and investigational procedure that is the subject of on-going clinical trials. Therefore, the request is considered 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 injection have not been met.Therefore, we decided that the Plan does not have to pre-approve genicular nerve injection to the knee for the enrollee.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a CT Scan of the abdomen and pelvis.
You asked the Plan to pre-approve the CT Scan. You say that the CT Scan is medically necessary. The Plan denied your request. The Plan says that past evaluations have not revealed a concerning etiology.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the CT Scan. Our reviewer says that the chronic nature of the member's pain and the fact that they have seen another specialist makes the CT Scan medically reasonable and necessary. Our physician reviewer found the lack of findings on the physical examination do not preclude the need for the CT scan. Any result will be beneficial in further evaluation of the member's pain. 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 CT Scan have been met. Therefore, we decided that the Plan has to pre-approve a CT Scan of the abdomen and pelvis.
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.