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

We decided that the Plan does not have to pre-approve additional routine transportation trips.You asked the Plan to pre-approve the additional trips. You say that you have appointments for the remainder of the year and need the transportation.The Plan denied your request. The Plan says the enrollee has exhausted the transportation benefit for the 2019 calendar year.Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 50 trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of the additional trips.Therefore, we decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower bench.You asked the Plan to pre-approve a shower bench. You say that you require the shower bench due to experiencing weakness and Sciatica nerves. You say that the bench will help prevent falls so you will not have to go to the hospital.The Plan denied your request. The Plan says this item is not a covered benefit.The Plan must follow Medicare rules. Medicare rules say that shower benches are not covered because they are not primarily medical in nature. While a shower bench 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 bench.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dual hose portable air conditioner (E1399) to be provided. You asked the Plan to pre-approve dual hose portable air conditioner. You say that do to your medical history you feel it is medically necessary.The Plan denied your request. The Plan says this item is not a covered benefit.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 dual hose portable air conditioner (E1399) to be provided.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion of an astigmatism correcting intraocular lens (A-C IOL).You asked the Plan to pre-approve insertion of an astigmatism correcting intraocular lens (A-C IOL). You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says insertion of an A-C IOL is not covered under Medicare or the plan.The Plan covers all items that Medicare covers. Medicare rules say that if an enrollee receives an A-C IOL during cataract surgery, the enrollee will be responsible for the difference in cost between the A-C IOL and a conventional IOL. While an A-C IOL may be appropriate for the enrollee, neither the Plan nor Medicare covers the astigmatism-correcting feature of an IOL.Therefore, we decided that the Plan does not have to pre-approve insertion of an astigmatism correcting intraocular lens (A-C IOL).
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 provider. You asked the Plan to pre-approvethese services. You say that you refuse to see a new PCP.The Plan denied your request. The Plan says the services are available from network providers.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The file shows that the requested provider has retired and is no longer practicing medicine. 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-approvethe medical services to be provided.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 8 hours of neuropsychological testing.
You asked the Plan to pre-approve the requested neuropsychological testing. You say that this additional testing should be allowed to assist in diagnosis and treatment planning. The Plan denied your request. The Plan says the previously approved testing should be sufficient to allow for adequate diagnosis and treatment planning. Additional testing is in excess of the enrollee's need.
The Plan follows Medicare rules. Medicare rules say that neuropsychological testing is considered necessary for the above described clinical scenarios. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the requested neuropsychological testing. Our reviewer says that the requested amount of this testing is not considered medically reasonable and necessary. Our physician reviewer found this 68-year-old female is requesting reimbursement for Neuropsychological testing CPT 1 unit x 96132 and 7 units x 96133 which is in addition to 15 units previously requested/authorized. Based on review of the records provided, it was noted that this patient's provider is asking for the additional procedure be used to collect data by a technician and decision-making treatment. On review the records provided in the information provided shows this patient to have strange auras and sensations. It is not clear as to the required extra time asked for in evaluation as it appears that the patient was adequately evaluated previously. Based on the information presented appears that the amount of time authorized is generous and adequate for the evaluation of this patient with symptoms presented. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the requested neuropsychological testing have not been met. Therefore, we decided that the Plan does not have to pre-approve 8 hours of neuropsychological testing.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lumbar laminectomy for the enrollee.
You asked the Plan to pre-approve these services. You say that the surgery is needed to improve the enrollee's quality of life. 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 a history of chronic low back pain radiating into the bilateral lower extremities with intermittent left lower extremity numbness. Clinical exam findings documented absent lower extremity deep tendon reflexes. He has failed to achieve sustained improvement with conservative treatment, including activity modification, medications, and epidural injections. Evidence based medical literature generally supports surgical decompression for the treatment of refractory degenerative lumbar spinal stenosis including in the setting of degenerative spondylolisthesis. However, in this case, there is no imaging report provided to support the medical necessity of surgical intervention at the L4/5 level. Therefore, this request for lumbar laminectomy has not been established as the standard of care for the treatment of this enrollee's medical condition, and would not be considered medically reasonable and 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-approve lumbar laminectomy for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Computed Tomography Calcium Scoring (75571).
You asked the Plan to pre-approve the calcium scoring. You say that the service is medically necessary. The Plan denied your request. The Plan says coverage criteria is not met.
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 calcium scoring. Our reviewer says that the service at issue is not medically necessary. Our physician reviewer found CCTA (computed coronary tomographic angiography) with contrast could be used for assessment of lower risk chest pain symptoms but CT calcium scoring alone, as is requested here, is not recommended or clinically appropriate based on published clinical literature 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 calcium scoring have not been met. Therefore, we decided that the Plan does not have to pre-approve Computed Tomography Calcium Scoring (75571).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve four further physical therapy (PT) visits.
You asked the Plan to pre-approve these services. You say that your vertigo is still being treated. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 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 these services. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the submitted records show that you have limited neck spine range of motion and mobility. Significant improvement is noted with the prior PT. Based on the records, you do not require the unique skills of a professional therapist to safely and effectively provide treatment. There are no updated medical notes that support that continued PT is reasonable and 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve four further physical therapy (PT) visits.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a transthoracic echocardiogram (TTE) with Doppler and stress TTE for the enrollee.
You asked the Plan to pre-approve these services. You say that the services are 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 had complete revascularization of this coronary anatomy with coronary artery bypass graft (CABG) in April of 2018. A post-op echo done in May of 2018 showed normal valvular function and normal left ventricular function. He is on appropriate medical therapy post-CABG as well. In the absence of symptoms or clinical signs within the first five years after coronary bypass surgery, routine stress testing is not recommended for sub-clinical ischemia in asymptomatic patients. The 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a transthoracic echocardiogram (TTE) with Doppler and stress TTE for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bronchial thermoplasty.You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the benefit of this type of treatment is still not proven.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the requested services. Our physician reviewer found that the enrollee has had worsening asthma for a number of years. She has frequent exacerbations requiring emergency room visits, and is currently dependent on systemic steroids. However, it is not clear that all of her respiratory symptoms are due to asthma. There is a history of vocal cord dysfunction, and she has significant tracheobronchialmalacia on chest CT scan. Pulmonary function tests show restriction rather than obstruction, without a bronchodilator response. Bronchial thermoplasty would not be expected to benefit these conditions, and the instrumentation could acutely aggravate the airway malacia. Further, she has a BMI greater than 40. The risks and benefits of the procedure are unknown for her, because morbidly obese patients were excluded from the clinical trials of bronchial thermoplasty. For these reasons, bronchial thermoplasty is considered 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 requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve a bronchial thermoplasty.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approveheavy duty extra wide hospital bed to be provided by "the provider" You asked the Plan to pre-approvethe hospital bed. You say that the enrollee is bed confined because of spinal surgery but does not fit in the bed that was ordered.The Plan denied your request. The Plan says the records do not support that this is medically necessary.The Plan must follow Medicare rules. The rules say that a hospital bed may be considered medically necessary when at least one of the following criteria is met:1. The patient has a medical conditions which requires positioning of the body in ways not feasible with an ordinary bed; or2. The patient requires positioning of the body in ways not feasible with an ordinary bed in order to alleviate pain; or3. The patient requires the head of the bed to be elevated more than 30 degrees most of the time due to congestive heart failure, chronic pulmonary disease, or problems with aspiration.  Pillows or wedges must have been considered and ruled out; or4. The patient requires traction equipment, which can only be attached to a hospital bed.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 hospital bed. Our reviewer says that this enrollee does not meet the criteria. Our physician reviewer found The records do not indicate the member 
requires frequent and/or immediate changes in body position or special bed attachments. The necessity for a hospital bed is not substantiated. As such, 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 hospital bed have not been met.Therefore, we decided that the Plan does not have to pre-approveheavy duty extra wide hospital bed to be provided by "the provider".
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve retainer crowns (D6740) for teeth # 5 and 7, and a pontic (D6245) for tooth # 6.You asked the Plan to pre-approve the retainer crowns, and pontic. You say that you are aware that bridges are not covered. You also say that there is clearly decay on teeth # 5 and 7 and core buildup is needed.The Plan denied your request. The Plan says retainer crowns are not listed as a covered service. The Plan also says that pontics are 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, retainer crowns and pontics are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approve retainer crowns (D6740) for teeth # 5 and 7, and a pontic (D6245) for tooth # 6.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve the periodontal scaling and root planing.You asked the Plan to pre-approve the periodontal scaling and root planing. You say that you have tartar along the gum line because you have not had a cleaning in a long time. You say that they would not do a regular cleaning.The Plan denied your request. The Plan says that the criteria for coverage has not been met.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 the periodontal scaling and root planing when the services are medically necessary and reasonable.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 periodontal scaling and root planing. Our reviewer says that the criteria for coverage has been met. Our reviewer says that the radiographs indicate the presence of 4-6 mm abnormal periodontal pockets in all four quadrants. Our physician reviewer found that based on the periodontal pathology, the scaling and root planing is reasonable and necessary.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the periodontal scaling and root planing have been met.Therefore, we decided that the Plan has to pre-approve the periodontal scaling and root planing.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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecustom myoelectric elbow-wrist-hand-finger orthosis (L8702) to be provided by the provider.You asked the Plan to pre-approvethe myoelectric arm. You say that you are appealing this denial as this is a medically necessary device and request review of the records.The Plan denied your request.The Plan says this service is considered experimental and investigational and therefore is not coveredThe Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The rules also say that experimental and investigational devices are not covered.  Based on this information, we decided that Medicare rules for coverage of the myoelectric arm have not been met.Therefore, we decided that the Plan does not have to pre-approvecustom myoelectric elbow-wrist-hand-finger orthosis (L8702) to be provided.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a retainer crown (D6752) for tooth # 5, a prefabricated abutment (D6056) for teeth # 21 and 28, and an implant (D6010) for teeth # 21 and 28 to be provided.You asked the Plan to pre-approve the dental services. You say that you had a bad accident. You say that you feel on your face and damaged a majority of your teeth. You also say that it is imperative that you have these services so that you do not have a setback with your eating disorder.The Plan denied your request. The Plan says the requested services 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 items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approve a retainer crown (D6752) for tooth # 5, a prefabricated abutment (D6056) for teeth # 21 and 28, and an implant (D6010) for teeth # 21 and 28 to be provided.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve surgery for migraine headaches. You asked the Plan to pre-approve the surgery. The Plan denied your request. The Plan says this is an experimental/investigational procedure. 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 surgery. Our reviewer says that the requested procedure is not considered medically reasonable and necessary in this case. Our physician reviewer found that the research and trials that have been done to date on surgical interventions for migraines, including one randomized prospective trials and retrospective analyses that have been performed have had significant methodological flaws and limitations. As a result the scientific evidence to date does not permit conclusions concerning the effect on health outcome. In as much the procedure remains within the research and experimental stage of the development. Given these methodological limitations there is insufficient evidence to make sound conclusions on effect on health outcome of the proposed surgery. Taking the AHS recommendation into consideration migraine surgery is still a procedure under development needing further clinical trials. This falls within the scope of a service service/procedure that is traditionally classified as being experimental/investigational. 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 surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve surgery for migraine headaches.