Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a medial branch block (MBB) injection.You asked the Plan to pre-approve medial branch block (MBB). You say that you are appealing because the enrollee did not have a positive response to Lidocaine.The Plan denied your request. The Plan says the denial of authorization for this service is correct, because there was no response from a previous injection. The Plan also says that they have approved the left side MBB due to previous response, therefore this denial is only for a right side MBB.The Plan follows Medicare rules. Medicare rules say that a second MBB is allowed only if documentation indicates that the first MBB produced at least 80% relief of primary pain.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 medial branch block (MBB). Our reviewer says that the enrollee does not meet the Medicare criteria for the requested MBB. Our physician reviewer found the previous diagnostic block did not achieve at least 80% pain relief, therefore the repeat procedure is not indicated and is 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 medial branch block (MBB) have not been met.Therefore, we decided that the Plan does not have to pre-approve a medial branch block (MBB) injection.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a knee walker (E0118).
You asked the Plan to pre-approve a knee walker. You say that the requested item is necessary since you are not supposed to put weight on your foot. The Plan denied your request. The Plan says a knee walker is not a covered item.
The Plan follows Medicare rules. Medicare rules say that Medicare only covers crutches or crutch substitutes if specific criteria is met. 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 knee walker. Our reviewer says that the item is not medically necessary. Our physician reviewer found that this is a convenience item and is not medically necessary above standard crutch use, or walking boot use. A knee walker/crutch is a convenience item as a lesser device can address mobility deficits. 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 knee walker have not been met. Therefore, we decided that the Plan does not have to pre-approve a knee walker (E0118).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean additional six (of the 12 requested) physical therapy (PT) visits.You asked the Plan to pre-approvethe additional PT visits. You say that the requested amount of PT visits are required.The Plan denied your request. The Plan says an additional six visits is sufficient to transition the enrollee to a home exercise program. Visits beyond that 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 the additional PT visits. 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 enrollee has been receiving physical therapy for back pain. At the time of the request. 17 had been previously approved. On appeal, 6 more visits were approved to educate on HEP. Physical therapy reports indicate the member is demonstrating understanding of a home program, and treatments have included neuromuscular reeducation, modalities for pain relief, core strengthening, and therapeutic exercises. Progress with PT is noted as steady.In this case, there is no indication prior PT has served to provide sustained, significant improvement in pain and/or function and there is no indication residual deficits could not be addressed via a home exercise 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 the additional PT visits have not been met.Therefore, we decided that the Plan does not have to pre-approvean additional six (of the 12 requested) physical therapy (PT) visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea Battery Operated Nebulizer (E0570).You asked the Plan to pre-approvethe battery powered nebulizer. You say that you need the battery powered nebulizer in case of power outages.The Plan denied your request. The Plan says it has already provided a standard Nebulizer in 2018. The battery powered nebulizer provides the same treatment.The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary.The file shows that you have a standard nebulizer. A standard nebulizer serves the same purpose as the battery powered nebulizer.Therefore, we decided that the Plan does not have to pre-approvea Battery Operated Nebulizer (E0570).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve twice daily 60 minute skilled nurse visits (G0299 and G0300). You asked the Plan to pre-approve twice daily 60 minute skilled nurse visits. You say that you need three one hour visits a day instead of two thirty minute visits.The Plan denied your request. The Plan says your needs can be met with thirty minute visits, which have been approved.The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.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 twice daily 60 minute skilled nurse visits. Our reviewer says that twice daily 60 minute skilled nurse visits are not medically necessary at this time. Our physician reviewer found the records indicate the patient requires a skilled nurse for glucose checks and insulin administration. It is reasonable that each of these visits could be accomplished in 30 minutes for each visit.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of twice daily 60 minute skilled nurse visits have not been met.Therefore, we decided that the Plan does not have to pre-approve twice daily 60 minute skilled nurse visits (G0299 and G0300)
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea seat lift chair.You asked the Plan to pre-approvethe seat lift mechanism of a seat lift chair. You say that you need a seat lift chairbecause of your back and knee pain. The Plan denied your request. The Plan says criteria for a seat lift mechanism have not been met.The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions listed above are met.We looked at this the file and Medicare rules. The assessmentshows you are able to stand up from chairs in your home.You do not have qualifying diagnoses. Based on this information, we decided that Medicare rules for coverage of the seat lift mechanism of a seat lift chair have not been met.Therefore, we decided that the Plan does not have to pre-approvea seat lift chair
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecrown recementation.You asked the Plan to pre-approvethese services. You say that this is necessary.The Plan denied your request. The Plan says that this is not covered by the 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-approvecrown recementation.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the evaluation and treatment to be provided by the out of network provider.You asked the Plan to pre-approve the physician services. You say that your eye doctor recommended a cataract extraction. You say that you would like to see the doctor that performed your keratoplasty years ago. The Plan denied your request. The Plan says the requested services can be provided in network.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and 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 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-approve the evaluation and treatment to be provided by the out of network provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve mental health residential services.
You asked the Plan to pre-approve the requested services. You say that you need extra support to help with your eating disorder. The Plan denied your request. The Plan says you do not need around the clock structure to adhere to the treatment.
The Plan follows Medicare rules. Medicare rules say that services must be for the purpose of diagnostic study or the services must reasonably be expected to improve the patient's condition.
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 you were found to be cooperative with care, actively involved in your treatment, and following through with treatment. You were not found to be a danger to yourself or others. You did not have any auditory or visual hallucinations. You were medically cleared and were not showing any medical instability. You do not meet the criteria for residential treatment as this patient was not a danger to yourself, and could be treated in a lesser restrictive environment.
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 mental health residential services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea partial upper denture (D5213) and a partial lower denture (D5214).You asked the Plan to pre-approvethe dental services. You say that the deep cleaning has been approved. You say that once you receive this service, 4 of your teeth will probably fall out as they are being held together by the plaque buildup. You also say that you will need partials immediately after.The Plan denied your request. The Plan says partial dentures 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 services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approvea partial upper denture (D5213) and a partial lower denture (D5214).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveOpdivo with Diphenhydramine HCL and Ondansetron HCL for the enrollee.You asked the Plan to pre-approvethese services. You say that this is medically necessary for the enrollee.The Plan denied your request. The Plan says that the request does not meet Medicare rules for medical necessity because there is no recommendation for systemic chemotherapy in Stage T1a in the NCCN compendia nor in the guidelines, nor in the current literature.The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 these services are not medically reasonable and necessary for the enrollee in this case. Opdivo is not FDA-approved for the enrollee's diagnosis, he has an increasing right upper lobe nodule that has not been biopsied. The use is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal without a tissue diagnosis. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these drugs.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-approveOpdivo with Diphenhydramine HCL and Ondansetron HCL for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pontic (D6240) for tooth # 31, and retainer crowns (D6750) for teeth # 30 and 32. You asked the Plan to pre-approve the a pontic, and retainer crowns. 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 pontic and retainer crowns are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approve a pontic (D6240) for tooth # 31, and retainer crowns (D6750) for teeth # 30 and 32.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a tiering exception for Performist Nebulizer solution for the enrollee.You asked the Plan to pre-approve a tier exception. You say that the enrollee requires a cost reduction.The Plan denied your request. The Plan says that Part B drugs are not eligible for a tiering exception.The Plan must follow Medicare rules. Medicare rules say that tier exceptions are only available for Part D drugs. The requested drug is covered under Part B. Based on this information, we decided that Medicare rules for coverage of a tier exception have not been met.Therefore, we decided that the Plan does not have to pre-approve a tiering exception for Performist Nebulizer solution for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by out of network providers.You asked the Plan to pre-approve specialist services. You say that you have been going to the same doctor for 19 years. You say that just because you moved to Tennessee you pay your dues and should be able to still see your doctor.The Plan denied your request. The Plan says there are in-network providers available.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 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-approve the medical services to be provided by out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the custom fabricated abutment (D6057).
You asked the Plan to pre-approve the custom fabricated abutment (D6057). You say that without the structure
in place you cannot have your bridge installed. You say that the Plan should cover more of the cost. The Plan
denied your request. The Plan says 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.
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 the
custom fabricated abutment (D6057).

Please note that this decision is only regarding the custom fabricated abutment with dental code D6057. Please
contact the Plan regarding appeals for any other items or services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2300 -power seat elevator, K0108 -drive lock out, E2311 -electrical connection, K0108 -four point wheelchair transit tie down, K0108 -high speed package). You asked the Plan to pre-approve the accessories. You say that this is medically necessary.The Plan denied your request. The Plan says these are not primarily medical in nature.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  The items 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. Our doctor found that the requested items are convenience items and not supported. There is no indication these accessories will meaningfully enhance MRADL's and/or mobility above a standard power mobility device. As such, the requested items are not medically necessary.Therefore, we decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2300 -power seat elevator, K0108 -drive lock out, E2311 -electrical connection, K0108 -four point wheelchair transit tie down, K0108 -high speed package).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not haveto pre-approve insertion of an interspinous spacer device.You asked the Plan to pre-approve the procedure. You say that this is medically necessary.The Plan denied your request. The Plan says this 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 procedure. Our reviewer says that the requested procedure is not medically reasonable or necessary. Our physician reviewer found this device is experimental, and more research is needed.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 procedure have not been met.Therefore, we decided that the Plan does not have to pre-approve insertion of an interspinous spacer device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve power seat elevation feature(E2300) power standing feature (E2301) 20 degree active forward reach (K0108) LED light kit (K0108) cup holder (K0108) and USB Charger (K0108).You asked the Plan to pre-approve the wheelchair accessories. You say that the records should support the necessity of the services The Plan denied your request. The Plan says these items are not primarily medical in nature and therefore not covered.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 power seat elevation feature(E2300) power standing feature (E2301) 20 degree active forward reach (K0108) LED light kit (K0108) cup holder (K0108) and USB Charger (K0108).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvefoot orthotics.You asked the Planto pre-approvefoot orthotics. You say that this is medically necessary.The Plandenied your request. The Plansaysthis 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 Plandoes not haveto pre-approvefoot orthotics
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the foreign body removal.You asked the Plan to pre-approve the foreign body removal. You say that you are in a lot of pain and your mouth is swollen. You say that you need to get the object removed.The Plan denied your request. The Plan says 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.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 the foreign body removal.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bath/shower chair.You asked the Plan to pre-approve a bath/shower chair. You say that this is medically necessary.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 bath/shower chair.