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

We decided that the Plandoes not haveto pre-approvePromethazine HCL 25mg tablets for the enrollee.You asked the Planto pre-approvethe drug. You say that this is medically necessary.The Plandenied your request. The Plansaysthis is not a covered 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 Plandoes not haveto pre-approvePromethazine HCL 25mg tablets.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued rental of the Trilogy Ventilator.You asked the Plan to pre-approve continued rental of the home ventilator. You say that you need the Trilogy Ventilator. The Plan denied your request. The Plan says you have not been compliant with this device. The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. We looked at the file and Medicare rules. Poor compliance suggests that the requested item is not reasonable and necessary for your treatment. Based on this information, we decided that Medicare rules for coverage of continued rental of the home ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve continued rental of the Trilogy Ventilator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvepower wheelchair seat elevation system, attendant control, armrests, push handles, and premier cushion.You asked the Plan to pre-approvea power wheelchair seat elevation system, attendant control, armrests, push handles, and premier cushion. You say that the enrollee needs the requested accessories.The Plan denied your request. The Plan says a joystick has been approved and therefore an attendant control cannot be covered in addition, a power seat elevation system is non-covered,push handles are not medical equipment, the cushion code is incorrect and the armrests exceed the member's needs.The Plan must follow Medicare rules. Medicare rules say options and accessories for wheelchairs are covered if the beneficiary has a wheelchair that meets Medicare coverage criteria and the option/accessory itself is medically necessary. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a power wheelchair seat elevation system, attendant control, armrests, push handles, and premier cushion have not been met.Therefore, we decided that the Plan does not have to pre-approvepower wheelchair seat elevation system, attendant control, armrests, push handles, and premier cushion.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Core Build Up (D2950) and Gingivectomy (D4212).You asked the Plan to pre-approve the Core Build Up and Gingivectomy. You say that the services were medically necessary.The Plan denied your request. The Plan says the services at issue 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 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 Core Build Up (D2950) and Gingivectomy (D4212).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprovea pneumatic compression device (E0676).You asked the Plan to preapprovea pneumatic compression device.You say that the device is necessary.The Plan denied your request. The Plan says the pneumatic compression device is not covered by Medicare to prevent deep vein thrombosis during and/or following surgery.The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service.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, this item is not a covered benefit of Medicare or the Plan. This item is used for a preventative service and is excluded from Medicare coverage.Therefore, we decided that the Plan does not have to preapprovea pneumatic compression device (E0676).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea shower chair.You asked the Plan to pre-approvea shower chair. You say that the requested shower chair is a medical necessity. You say that you are fearful of falling in the shower because you are at a high risk of getting hurt.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 chairs are not covered because they are not primarily medical in nature. While a showerchair 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-approvea shower chair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean alveoloplasty not in conjunction with an extraction (D7320) for the upper left quadrant.You asked the Plan to pre-approvethe dental service. The Plan denied your request. The Plan says the requested service 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 service is not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approvean alveoloplasty not in conjunction with an extraction (D7320) for the upper left quadrant.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approveEnbrel.You asked the Plan to pre-approveself-administered drug. You say that the enrollee has been onthis medication since 2004, and will most likely be hospitalized if this drug is discontinued.The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because this drug is not covered by Medicare Part B and the Plan does not administer the enrollee's Medicare Part D prescription drug benefits.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-approveEnbrel.Benefits for self-administered drugmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveLinzess for the enrollee.You asked the Plan to pre-approveLinzess. You say that this is medically necessary for the enrollee.The Plan denied your request. The Plan says that this is not covered under the enrollee's 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-approveLinzess for the enrollee.Benefits for Linzessmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve oral nutritional supplement.You asked the Plan to pre-approve. You say that you need this because you are struggling to put on weight.The Plan denied your request. The Plan says that this is not covered because you are not using a feeding tube.The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation.The items you asked the Plan to pre-approve are nutritional supplements.Therefore, we decided that the Plan does not have to pre-approve oral nutritional supplement.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecompression stockings identified with code A6549.You asked the Plan to pre-approvethe compression stockings. You say that you require the stockings after venous closure procedure. Additionally, you have tried the tighter version of the stockings but they cause too much discomfort.The Plan denied your request. The Plan says wound care items which are non-covered under the surgical dressing benefit because they do notmeet the statutory definition of a dressing.The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 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 Plan does not have to pre-approvecompression stockings identified with code A6549
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the ferumoxytol injections provided on September 17, 2019 and September 23, 2019.
You asked the Plan to waive the coinsurance for the injections. You say that you did not realize what the cost would be. The Plan denied your request. The Plan says that you were charged correctly.
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 20% coinsurance for Medicare Part B prescription drugs. You have been asked to pay 20% coinsurance for the injections. The injections fall within the Medicare Part B prescription drugs 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 coinsurance for the ferumoxytol injections provided on September 17, 2019 and September 23, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CardioMEMS procedure.
You asked the Plan to pre-approve CardioMEMS procedure. You say that you are appealing with medical records. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because the CardioMEMS procedure is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve CardioMEMS procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found therapy change based on data obtained from a CardioMEMS device has been demonstrated in only 1 trial to help reduce hospital re-admission compared to standard medical therapy. However, concerns have been raised about potential bias in this trial calling into question the results. Therefore the efficacy of the CardioMEMS device is uncertain at this time according to leading authorities and not recommended in current guidelines for the treatment of heart failure. Medicare coverage rules are not met because this device is considered experimental or 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 CardioMEMS procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve a CardioMEMS procedure.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approveEuflexxa.You asked the Plan to pre-approveEuflexxa. You say that the requested Euflexxa is medically necessary.The Plan denied your request. The Plan says the enrollee has not tried and failed the plan's preferred drugs, Monovisc and Orthovisc first.Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying therequest to pre-approve Euflexxa. Our reviewer says that the Plan's step therapy criteria have not been met. Our physician reviewer found the enrollee is with pain related to osteoarthritis of the right knee, confirmed with x-rays, and has failed conservative treatment. The provided medical records do not indicate that the enrollee has tried and failed the required drugs. The provided medical records do indicate that the enrollee has an allergy to eggs thus Orthovisc would be contraindicated based on the Medicare-approved compendium, Micromedex. Monovisc however has no such contraindication -it is derived from bacterial cells -there is no indication that Monovisc would likely be less effective and/or likely have adverse effects for the enrollee.We lookedat this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Euflexxa have not been met.Therefore, we decided that the Plan does not have to pre-approveEuflexxa
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve office visits with out of network provider. You asked the Plan to pre-approve out-of-network office visits. You say that there is too long a wait for in-network providers.The Plan denied your request. The Plan says there are in-network providers with availability within two weeks.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 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 office visits with out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (D2750) for tooth # 6.You asked the Plan to pre-approve the dental services. The Plan denied your request. The Plan says crowns 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, 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 crown (D2750) for tooth # 6.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approveguided tissue regeneration (D4267) for tooth # 18, and a bone graft (D7953) for tooth # 30, the core build up (D2950) for teeth # 3 and 19, a porcelain crown (D2740) for teeth# 3 and 19, and periodontal scaling (D4346).You asked the Plan to pre-approvethe guided tissue regeneration, and bone graft. You say that  The Plan denied your request. The Plan says guided tissue regeneration is not listed as a covered service. The Plan also says that bone grafts 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, guided tissue regeneration and bone grafts are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approveguided tissue regeneration (D4267) for tooth # 18, and a bone graft (D7953) for tooth # 30, the core build up (D2950) for teeth # 3 and 19, a porcelain crown (D2740) for teeth # 3 and 19, and periodontal scaling (D4346).
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 it is imperative for the enrollee's well-being to get the shower bench. You say that due to the enrollee's various conditions, the shower bench is necessary in order for the enrollee to bathe on a regular basis.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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral at the in-network rate.You asked the Plan to pre-approve these services. You say that the provider knows your medical history.The Plan denied your request. The Plan says the services are available from network providers at the in-network rate.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 $60 copayment for each out-of-network specialist visit for Medicare-covered services. The requested provider is not a network provider with the Plan. If you choose to receive services with this provider, you will be asked to pay a $60 copayment for these services. These services fall within the out-of-network specialist visit for Medicare-covered services 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. The Plan has network providers from which you may receive services at the network rate. Therefore, we decided that the Plan does not have to pre-approve at the in-network rate.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.You asked the Plan to pre-approve foot orthotics. You say that you are pain free with inserts.The Plan denied your request. The Plan says this item is not a covered benefit.Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.  Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition.Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve periodontal maintenance (D4310), a resin based composite for 2 surfaces on an anterior tooth (D2331) for teeth # 24 and 25, and a resin based composite for 3 surfaces on an anterior tooth (D2332) for tooth # 27.You asked the Plan to pre-approve the dental services. The Plan denied your request. The Plan says periodontal maintenance is not a covered service. The Plan says that only 2 fillings are covered per year. The Plan also says that resin based composites for 3 surfaces on an anterio rtooth 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, periodontal maintenance, and a resin based composite for 3 anterior surfaces on an anterior tooth are not among those covered under this benefit. Additionally, the resin based composite for 2 surfaces on an anterior tooth for teeth # 24 and 25 are not covered because the frequency limit has been reached. The record shows that the Plan previously approved 2 fillings for teeth # 18 and 20.Therefore, we decided that the Plan does not have to pre-approve periodontal maintenance (D4310), a resin based composite for 2 surfaces on an anterior tooth (D2331) for teeth # 24 and 25, and a resin based composite for 3 surfaces on an anterior tooth (D2332) for tooth # 27.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.You asked the Plan to pre-approve foot orthotics. You say that you have unequal limb length and you need a shoe lift to relieve pain and manage your balance.The Plan denied your request. The Plan says this item is not a covered benefit.Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.  Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition.Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe non-emergency ambulance transportation for specialist office visit with the provider.You asked the Plan to pre-approvethe ambulance transportation. You say that this should be covered because you had hip surgery and cannot walk and need the transportation.The Plan denied your request. The Plan says a physician's office is not a covered destination for non-emergency ambulance transportation and is therefore not covered.The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when they meet certain origin and destination requirements. A doctor's office is not a covered destination. The services you have asked the Plan to pre-approve are ambulance transport services to a doctor's office.Therefore, we decided that the Plan does not have to pre-approvethe non-emergency ambulance transportation for specialist office visit.