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

We decided that the Plan does not have to pre-approveoncology consultation services to be provided by an out of network (OON) provider.You asked the Plan to pre-approveoncology consultation services. You say that you would like the plan to reconsider their denial.The Plan denied your request. ThePlan says the requested services can be provided by a network provider.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-approveoncology consultation services to be provided by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea CT scan of the abdomen and pelvis (74178).You askedthe Plan to pre-approvea CT scan of the abdomen and pelvis. You say that these services are medically necessary.The Plan denied your request. The Plan says rules for pre-approvalfor a CT scanhave not been 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 a CT scan of the abdomen and pelvis. Our reviewer says that there is no documentation that a CT scan is medically reasonable and necessary in this case. Our physician reviewer found that the provided records do not document any physical examination or laboratory findings with regard to the complaint of pelvic pain and diarrhea. Inadequate information is available in the provided records to support necessity of the requested CT scan.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 CT scan of the abdomen and pelvis have not been met.Therefore, we decided that the Plan does not have to pre-approvea CT scan of the abdomen and pelvis (74178)
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone replacement graft, collection and application of autologous blood concentrate product, and biological materials to aid in soft and osseous tissue regeneration.
You asked the Plan to pre-approve bone replacement graft, collection and application of autologous blood concentrate product, and biological materials to aid in soft and osseous tissue regeneration. You say that you have two broken teeth in your gums that are very painful. The Plan denied your request. The Plan says the requested services are 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 bone replacement graft, collection and application of autologous blood concentrate product, and biological materials to aid in soft and osseous tissue regeneration.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Signia Styletto Connect 7NX or Connect 7X hearing
aids.
You asked the Plan to pre-approve the Signia Styletto Connect 7NX or Connect 7X hearing aids. You say that
you have undergone evaluation by your ENT, you have had a trial of medication and exams, tested and trialed
multiple different hearing aid brands and models all without help. You say that most of the models are either
incompatible with your ear or intolerable due to lack of settings/adjustability, and while some of the more
advanced models seemingly are better they have all caused you significant tinnitus, headaches and agitation
aside from the issues associated with their poor design. The Plan denied your request. The Plan says only
"Advanced" hearing aids and services from the Plan hearing provider are covered.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that
exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case.
We looked at the file and the Plan's rules. The file shows that the Plan's hearing aid benefit is limited to
"Advanced" hearing aids provided by the Plan's hearing aid provider. Therefore, we decided that the Plan does
not have to pre-approve Signia Styletto Connect 7NX or Connect 7X hearing aids.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve moderate sedation services.
You asked the Plan to pre-approve moderate sedation services. 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 medically necessary.
The Plan follows Medicare rules. Medicare rules say that local anesthesia or minimal conscious sedation may be appropriate. Use of moderate sedation and Monitored Anesthesia Care (MAC) is usually unnecessary. Documentation must clearly establish the need for such sedation in the specific patient. 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 moderate sedation services. Our reviewer says that the documentation does not support that the requested services are not medically necessary. Our physician reviewer found the documentation does not support a diagnosis, condition, and/or symptoms that would meet an ASA 3 status for this enrollee or meet the Medicare criteria for coverage. There is nothing in the enrollee's record indicating that it is medically necessary to have an anesthesiologist present during the radiofrequency ablation procedure. Therefore, the enrollee does not meet criteria for the requested 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 moderate sedation services have not been met. Therefore, we decided that the Plan does not have to pre-approve moderate sedation services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation system.
You asked the Plan to pre-approve the system. You say that this is medically necessary to assist with activities
of daily living. The Plan denied your request. The Plan says this 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 a power seat elevation system.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approvea septoplasty (30520), a submuccousresection (30140), a tonsillectomy and adenoidectomy (42821), and a palatopharyngoplasty (42145).You asked the Plan to pre-approvea septoplasty, a submuccous resection, a tonsillectomy and adenoidectomy, and a palatopharyngoplasty.. You say that this is an alternative to a CPAP because you are claustrophobic.The Plan denied your request. The Plan says that this is not indicated.The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 a septoplasty, a submuccous resection, a tonsillectomy and adenoidectomy, and a palatopharyngoplasty.. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found the records show that you have a deviated septum and would benefit from a septoplasty to correct the deviation. You have hypertrophied inferior turbinates and would benefit from a turbinate reduction. Your tonsils are large for your age and are likely contributing to your upper airway resistance. The elongated uvula would also improve with surgery. You have been diagnosed with obstructive sleep apnea (OSA) since 2007, and it has not resolved on its own. You are unable to tolerate the CPAP due to claustrophobia.In addition, with mild OSA, surgery may be curative and you would not need the CPAP long-term. The procedures are medically reasonable and 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 a septoplasty, a submuccous resection, a tonsillectomy and adenoidectomy, and a palatopharyngoplasty. have been met.Therefore, we decided that the Plan has to pre-approvea septoplasty (30520), a submuccous resection (30140), a tonsillectomy and adenoidectomy (42821), and a palatopharyngoplasty (42145).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are not medically necessary.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not medically necessary. Our physician reviewer found the enrollee was admitted for respiratory failure, chronic obstructive pulmonary disease (COPD) exacerbation, and community-acquire pneumonia. His medical conditions are stable,and he has no complex nursing or rehabilitation needs. He does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveuse of pembrolizumab.You asked the Plan to pre-approvepembrolizumab. You say that you are appealing.The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because pembrolizumab is not supported for your type of cancer.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 pembrolizumab. Our reviewer says that you do not meet the Medicare criteria for the requested use of pembrolizumab. Our physician reviewer found the requested use of pembrolizumab is not approved by the Food & Drug Administration (FDA) for your diagnosis of bladder cancer. The requested use is not supported in any of the Medicare-approved drug compendia.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of pembrolizumab have not been met.Therefore, we decided that the Plan does not have to pre-approveuse of pembrolizumab.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approveendodontic therapy (D3320) for tooth number 20.You asked the Plan to pre-approvethis service. You say that you are requesting a reconsideration of the Plan's denial.The Plan denied your request. The Plan says this service is not a covered benefit under your contractual policy. 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-approveendodontic therapy (D3320) for tooth number 20
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Low Dose Computed Tomography (LDCT) Lung
Cancer Screening (G0297).
You asked the Plan to pre-approve the LDCT Lung Cancer Screening. You say that the screening is medically
necessary. The Plan denied your request. The Plan says rules for coverage have not been met.
The Plan must follow Medicare rules. Medicare rules say that beneficiaries must meet the age criteria of 55-77
years for a LDCT Lung Cancer Screening to be covered.
We looked at the file and Medicare rules. The enrollee no longer falls within the covered age range. Based on
this information, we decided that Medicare rules for coverage of the LDCT Lung Cancer Screening have not
been met. Therefore, we decided that the Plan does not have to pre-approve a Low Dose Computed
Tomography (LDCT) Lung Cancer Screening (G0297).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
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 services are not covered.
The Plan must follow Medicare rules. Medicare rules say that a therapeutic CGM is covered when specific
criteria are met.
We looked at the file and Medicare rules. The file shows that the enrollee does not test their blood sugar levels
four or more times per day. 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 continuous
glucose monitor (CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve pulsed radiofrequency ablation (RFA).
You asked the Plan to pre-approve these services. You say that the procedure has worked in the past. The Plan
denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that pulsed RFA is not covered.
We looked at the file and Medicare rules. The services at issue are pulsed RFA. These services are not covered
by Medicare. Therefore, we decided that the Plan does not have to pre-approve pulsed radiofrequency ablation
(RFA).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex Superion interspinous device for the
enrollee.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your
request. The Plan says medical studies have not proven that this device is helpful for treatment of the health
problem.
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 device. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found the device is experimental. More research is needed to show the safety and efficacy of the procedure.
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 device have not been met. Therefore, we decided that the Plan does not have
to pre-approve the Vertiflex Superion interspinous device for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the removal of lateral exostosis (D7471).
You asked the Plan to pre-approve the removal of lateral exostosis. You say that the service is medically
necessary. The Plan denied your request. The Plan says the requested service is not covered.
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
removal of lateral exostosis (D7471).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea portable oxygen concentrator.You asked the Plan to pre-approvea portable oxygen concentrator. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says you do not meet criteria for the requesteditem.The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. The documentation supports that the item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home.Therefore, we decided that the Plan does not have to pre-approvea portable oxygen concentrator.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean exception to the sixty-mile limit for routine transportation.You asked the Plan to pre-approveexceptions to supplemental benefits. You say that you require this transportation.The Plan denied your request. The Plan says that the records show the shortest distance from themember's address to the destination is 72.6 miles.Medicare does not cover routine transportation. While plans may offer supplemental transportation benefits they are not required to do so. Medicare does not provide exceptions to supplemental benefits.Therefore, we decided that the Plan does not have to pre-approvean exception to the sixty-mile limit for routine transportation.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied
your request. The Plan says movement to a skilled nursing facility is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed above are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the admission. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing
service needs. You do not require skilled nursing or therapy services on a daily basis. You do not meet severity
of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the admission have not been met. Therefore, we decided that the Plan does not
have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveProlia.You asked the Plan to pre-approveProlia. You say that the requested Prolia is medically necessary.The Plan denied your request. The Plan says the enrollee must try and fail an oral bisphosphonate and zoledronic acid.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 Prolia. Our reviewer says that the Plan's step therapy criteria have not been met. Our physician reviewer found based on the documentation provided, the enrollee is noted to have osteoporosis, for which she has previously taken an oral bisphosphonate. A request has been made for Prolia to further treat the osteoporosis. The health plan requires that both and oral bisphosphonate and Reclast be tried first.There is no evidence that the enrollee is allergic to or intolerant of Reclast.There is no evidence that the enrollee has tried and not responded to Reclast. There is no documentation as to why Reclast would not be expected to be safe and effective for the enrollee.Therefore, the requested Prolia is not shown to be currently medically necessary and reasonable.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have not been met.Therefore, we decided that the Plan does not have to pre-approveProlia
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvesupply allowance for therapeutic continuous glucose monitor (CGM) (K0553).You asked the Plan to pre-approvesupply allowance for CGM. You say that you don't need the reader for the Free Style Libre as you already have one. You just need the sensors. Please reconsider the decision.The Plan denied your request. The Plan saysthe enrollee does not meet the criteria as the enrollee checks blood glucose 3 times a day, takes medications for diabetes but does not take insulin.The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medicallyreasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testingresults.We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment ofinsulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of supply allowance for CGM have not been met.Therefore, we decided that the Plan does not have to pre-approvesupply allowance for therapeutic continuous glucose monitor (CGM) (K0553).