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

We decided that the Plan does not have to pre-approve the crowns (D2750) for teeth # 7 and 20.
You asked the Plan to pre-approve the dental services. You say that you would like crowns to be placed on your front teeth. The Plan denied your request. The Plan says crowns are not 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 the crowns (D2750) for teeth # 7 and 20.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cooled radiofrequency ablation (RFA) of the genicular
nerves.

You asked the Plan to pre-approve the RFA. The Plan denied your request. The Plan says this 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 the RFA. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found that this an experimental/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 RFA have not been met. Therefore, we decided that the Plan does not have
to pre-approve cooled radiofrequency ablation (RFA) of the genicular nerves.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics (L3000).
You asked the Plan to pre-approve foot orthotics. You say that foot orthotics are medically necessary. The Plan denied your request. The Plan says you do not meet criteria for coverage of this item.
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. With the exception of enrollees who wear a leg brace, orthopedic footwear billed using codes L3000-L3649 will be denied as noncovered. The Plan follows these same rules. We reviewed the case file and Medicare rules. Based upon this review, we find that your request does not meet Medicare criteria for coverage. Specifically, the record shows that you have a history of diabetes mellitus without complications. The documentation provided does not indicate that you use an external leg brace or have a shoe that is an integral part of a covered brace. Although you do have diabetes, different codes are used to request orthotics to be placed in diabetic shoes for the prevention of foot ulcers. Medicare rules state that with the exception of enrollees who wear a leg brace, orthopedic footwear billed using code L3000 will be denied as noncovered. Therefore, we decided that the Plan does not have to pre-approve foot orthotics (L3000).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a replacement continuous positive airway pressure (CPAP) device.
You asked the Plan to pre-approve CPAP. You say that you did not put the card into the machine correctly, so it was not working, and some parts of the machine have come off, but it is still usable. The Plan denied your request. The Plan says the denial of authorization for a replacement device is correct, because your CPAP machine is still functional and has not been evaluated by a durable medical equipment supplier and determined to be irreparable.
The Plan must follow Medicare rules. Medicare rules say that DME items which are owned or are capped rentals may be replace in cases of loss, irreparable damage, or irreparable wear taking into consideration the reasonable useful lifetime of the item. We looked at the file and Medicare rules. Your CPAP machine is less than 5 years old and is therefore within its reasonable useful lifetime. Your machine is also not lost and has not suffered irreparable damage or irreparable wear. If you believe your CPAP machine requires repairs, please contact the Plan to discuss your options for having the machine evaluated and potentially repaired if necessary. Based on this information, we decided that Medicare rules for coverage of CPAP replacement have not been met. Therefore, we decided that the Plan does not have to pre-approve a replacement continuous positive airway pressure (CPAP) device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a ramp (A9270).
You asked the Plan to pre-approve a ramp. You say that you are appealing for the ramp because you cannot get in and out of your home because you now have a wheelchair. The Plan denied your request. The Plan says this is a self-help or convenience item and is 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 a ramp (A9270).
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 it is extremely hard to walk and get around. 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an additional residual limb support system for wheelchair.
You asked the Plan to pre-approve an additional residual limb support system for wheelchair. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the requested item is not a covered benefit.
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 the enrollee has a residual limb support system. The enrollee's approved residual limb support system serves the same purpose as the additional requested residual limb support system. Therefore, we decided that the Plan does not have to pre-approve an additional residual limb support system for wheelchair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an extraction (D7250) for tooth #30 and fixed bridgework (D6740, D6245) for teeth #28 to #31.
You asked the Plan to pre-approve the extraction and bridgework. You say that tooth #30 is decayed beyond saving and requires extraction. The patient has an existing bridge from several years ago that is currently failing. Removing the current bridge and placing a removable partial denture would not work because tooth #28 is attached to the bridge. You want to extract the decaying tooth and extend the current bridge to the next tooth. The Plan denied your request. The Plan says the extraction requested is a surgical/residual root removal. The documentation does not support this extraction type, but another may be considered. The documentation also does not show why partial dentures cannot be used instead of a fixed bridge.
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 extraction and bridgework 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 extraction and bridgework. Our reviewer says that the criteria for these services have not been met. Our physician reviewer found that tooth #30 had prior endodontics and is heavily decayed and failing. There is no reasonable method to save this tooth, and extraction is indicated. The original request for a removal of residual tooth roots (D7250) should be denied, but a recoded extraction should be considered for approval at the Plan level. The treatment plan regarding fixed bridgework is not unreasonable, but the Plan has criteria for whether a bridge should be approved for coverage.
These criteria are based upon the finding if there is a physical or neurological deficit that prevents the member from using a removable appliance. With such a deficit, a fixed appliance could be considered. In cases where there is no documentation showing why a removable appliance cannot be used, the Plan does not consider fixed bridgework a covered service. A bridge cannot be considered as there is no documentation of a deficit that prevents the use of a removable appliance in this case. The Plan's criteria have not been met. 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 extraction and bridgework have not been met. Therefore, we decided that the Plan does not have to pre-approve an extraction (D7250) for tooth #30 and fixed bridgework (D6740, D6245) for teeth #28 to #31.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve residential treatment center care.
You asked the Plan to pre-approve residential treatment center care. You say that you would like the Plan to reconsider their denial for these services. The Plan denied your request. The Plan says the requested service is not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that inpatient psychiatric treatment is only covered when a patient receives care in psychiatric hospitals, and distinct part psychiatric units of acute care hospitals and critical access hospitals. We looked at the file and Medicare rules. In this case, you are requesting care in a residential treatment center which is not a covered benefit. Based on this information, we decided that Medicare rules for coverage of residential treatment center care have not been met. Therefore, we decided that the Plan does not have to pre-approve residential treatment center care.
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 services are medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found while the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care.

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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an electronic connection (E2311), expandable controller (E2377) and expandable controller harness (E2313) for the enrollee.
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the member's upper limb strength and function are adequate for the member to be able to control the power options using their own switches which are included in the allowance of these power options.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Records indicate the enrollee is independent with self-feeding and do not document upper extremity weakness to be so severe as to be unable to control the power options with their own switches. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve an electronic connection (E2311), expandable controller (E2377) and expandable controller harness (E2313) for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Fasenra 30 mg/ml once every 4 weeks.
You asked the Plan to pre-approve Fasenra. You say that this request is medically necessary. The Plan denied your request. The Plan says the available medical records do not support necessity of the drug at this dosing frequency as defined by Medicare criteria
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved 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 Fasenra. Our reviewer says that the requested drug is not medically necessary and reasonable. Our physician reviewer found that the enrollee is a 56-year-old male with a past medical history of severe persistent asthma. Based on the medical records provided and the Medicare-approved major drug compendia there is no documentation that use of Fasenra 30 mg/ml once every 4 weeks is Food and Drug Administration-approved for the enrollee's diagnosis. The Food and Drug Administration has approved Fasenra 30 mg/ml once every 4 weeks for the first three doses and then once every 8 weeks. In addition, Fasenra 30 mg/ml once 4 weeks is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. There is no documentation that supports that the requested drug at 30 mg/ml every 4 weeks as an ongoing regimen is safe and effective and otherwise reasonable and necessary for this enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Fasenra have not been met. Therefore, we decided that the Plan does not have to pre-approve Fasenra 30 mg/ml once every 4 weeks.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve wound cleansers (A6260).
You asked the Plan to pre-approve the cleansers. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that wound cleansers are not covered. The requested item is not a covered wound care benefit. Based on this information, we decided that Medicare rules for coverage of the cleansers have not been met. Therefore, we decided that the Plan does not have to pre-approve wound cleansers (A6260).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ten (10) additional physical therapy sessions, for the enrollee.
You asked the Plan to pre-approve the physical therapy. 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. 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 physical therapy. 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 based on the medical records provided there is no documentation that the requested therapy is generally accepted as specific and effective therapy for the enrollee's condition. The enrollee appears to be at the level of repetitive exercise which does not require skilled physical therapy service. There is no documentation that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist or under the supervision of a therapist. The enrollee appears to be at the level of repetitive exercise which does not require skilled physical therapy service. There is no documentation that the specialized skill, knowledge and judgment of a qualified therapist is required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration. Based on the records supplied the enrollee appears to be at the level of repetitive exercise which does not require skilled physical therapy service.
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 physical therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve ten (10) additional physical therapy sessions, for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia.
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 the step therapy requirement is not met.
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 the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has age-related osteoporosis without fracture confirmed on bone density testing. She has not tried and failed the Plan's required drug, zoledronic acid. The records do not show that the required drug would be contraindicated or less effective; therefore, Prolia is 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 Prolia.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral for foot orthotics out-of-network.
You asked the Plan to pre-approve the referral. You say that you were told that this provider was contracted. The Plan denied your request. The Plan says the requested provider is not 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 care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. 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 a referral for foot orthotics out-of-network.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an air purifier.
You asked the Plan to pre-approve an air purifier. You say that you live with smokers and it is affecting your health. The Plan denied your request. The Plan says air cleaners are not covered by Medicare or the Plan.
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 an air purifier.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an epidural steroid injection.
You asked the Plan to pre-approve an epidural steroid injection. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that no more than a single level bilaterally can be provided. We looked at the file and Medicare rules. Review of the file shows that one of the requested levels (L5-S1) was already approved by the plan. This means that no additional levels can be approved. Based on this information, we decided that Medicare rules for coverage of an epidural steroid injection have not been met. Therefore, we decided that the Plan does not have to pre-approve an epidural steroid injection.