Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that an IRF admission is medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of an IRF admission.

The Plan must follow Medicare rules. The rules say that an 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 that the complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for revision of a hip arthroplasty after a fall. His medical conditions are stable. There are no complex nursing or rehabilitation needs.

The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The patient does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care.

Additionally, there is not a reasonable expectation that this patient 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-approve an acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the bioimpedance spectroscopy (93702).

You asked the Plan to pre-approve the bioimpedance spectroscopy. You say that you believe the use of this device is medically necessary considering the enrollee's medical history. The Plan denied your request. The Plan says bioimpedance spectroscopy is considered investigational and experimental.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The rules also say that experimental and investigational devices are not covered.

We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the bioimpedance spectroscopy have not been met. Therefore, we decided that the Plan does not have to pre-approve the bioimpedance spectroscopy (93702).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a partial lower denture (D5214).

You asked the Plan to pre-approve the dental services. You say that the dentures you received in 2019 fell off. You say that 2 teeth are stuck in the acrylic on both sides. You also say that it is very hard to eat. The Plan denied your request. The Plan says dentures are covered once every 5 plan years. The Plan also says that the frequency limits have been reached.

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 and dentures are listed as covered, the frequency limits have been reached. The record shows that the Plan paid for a complete upper denture and a partial lower denture that you received on July 19, 2019. Therefore, we decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a partial lower denture (D5214).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips.

You asked the Plan to pre-approve routine transportation. You say that you need these trips to go to your appointments, and you currently have no one to take you. The Plan denied your request. The Plan says the denial of authorization for additional routine transportation is correct, because routine transportation beyond 52 one-way trips per year is not covered.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 52 trips per year.

We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an interspinous spacer procedure.

You asked the Plan to pre-approve insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level (22869). You say that the enrollee needs this procedure for pain relief. The Plan denied your request. The Plan says a review of the current medical literature indicates that this service 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 insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level (22869).

Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found interspinous process distraction devices remain experimental for the treatment of lumbar spinal stenosis. More research is needed to show safety and efficacy of the interspinous process distraction devices. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level (22869) have not been met. Therefore, we decided that the Plan does not have to pre-approve an interspinous spacer procedure.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve a trigger point injection.

You asked the Plan to pre-approve trigger point injection. You say that you are in a lot of pain and need this injection.The Plan denied your request. The Plan says that this is not medically necessary. 

The Plan follows Medicare rules. Medicare rules state that trigger point injections may be covered under certain clinical indications.

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 trigger point injection. Our reviewer says that you meet the Medicare criteria for the requested trigger point injection. Our physician reviewer found you have a diagnosis of pain in your right hip with active and passive range of motion of the right hip and thigh. Your pain was reported to be severe and interrupted your sleep. Your evaluation was consistent with a trigger point according to detailed history and thorough physical examination.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of trigger point injection have been met.Therefore, we decided that the Plan has to pre-approve a trigger point injection.

If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Tresiba Flextouch 200 unit injection.

You asked the Plan to pre-approve Tresiba Flextouch. You say that this is medically necessary. The Plan denied your request. The Plan says drug coverage is limited only to those drugs covered under your 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-approve Tresiba Flextouch 200 unit injection.

Benefits for Tresiba Flextouch may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a replacement prostheses (L5301, L5620, L5629,
L5637, L5645, L5671, L5673, L5910, L5940, L5986, L5987, L8420, L8470) to be provided by an OON
provider.

You asked the Plan to pre-approve the replacement prostheses. You say that the enrollee is a previous patient of
yours and he still wants to see you for his prosthetic needs. The Plan denied your request. The Plan says
enrollee's must receive their medical services from an in-network provider with the exception being urgent or
emergent services. Non-emergent services with non-contracted providers require prior authorization before
services being rendered.

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 replacement prostheses (L5301, L5620, L5629, L5637, L5645, L5671, L5673, L5910, L5940, L5986, L5987,
L8420, L8470) to be provided by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for retainer crown -porcelain fused to high noble metal (D6750), and the pontic -porcelain fused to high noble metal (D6240) received February 3, 2021.

You asked the Plan to pay for the retainer crown and the pontic. You say that you cannot afford to pay this bill and the Plan should pay a portion of the cost.The Plan denied your request. The Plan says the requested services are not covered under your supplemental 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 pay for retainer crown -porcelain fused to high noble metal (D6750), and the pontic -porcelain fused to high noble metal (D6240) received February 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve out-of-network cardiology services.

You asked the Plan to pre-approve out-of-network cardiology services. You say that she has been seeing her current cardiologist for 25 years and does not wish to change specialists.The Plan denied your request. The Plan says in-network providers are 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 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 out-of-network cardiology services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve specialist services to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve specialist services. You say that you would like these services approved. The Plan denied your request. The Plan says there are in-network providers available for these services.

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 specialist services to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve a personal emergency response system.

You asked the Plan to pre-approve personal emergency response system. You say that the enrollee is elderly
and lives alone, and this device would play a role in protecting her. The Plan denied your request. The Plan
says that the denial of authorization for this device is correct, because the enrollee does not have a history of
falls.

The Plan must follow Medicare rules. Medicare rules say that Medicare does not cover equipment that is
primarily and customarily used for non-medical purposes or for the comfort or convenience. The Plan has a
supplemental benefit that goes beyond Medicare coverage, for that reason the Plan's rules apply. The Plan
covers a personal emergency response system, and the enrollee's contract with the Plan does not clearly
disclose that any specific criteria must be met for coverage of a personal emergency response system.

We looked at the file, the Plan's rules, and Medicare rules. The Plan says that the enrollee does not meet the
criteria for coverage of a personal emergency response system because she does not have a history of falls;
however, the Plan contract does not clearly disclose that this is a required criterion for coverage of a personal
emergency response system. The Plan contract does not clearly disclose that any particular criteria are required
for coverage of a personal emergency response system under the Plan's supplemental benefit. Based on this
information, we decided that the Plan's rules for coverage of personal emergency response system have been
met. Therefore, we decided that the Plan has to pre-approve a personal emergency response system.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core buildup, including any pins when required (D2950).
You asked the Plan to pre-approve core buildup. You say that you would like the service covered. The Plan denied your request. The Plan says this service is not covered under your dental 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 core buildup, including any pins when required (D2950).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Lorazepam.

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 self-administered drugs are not covered.

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-approve Lorazepam.

Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a prefabricated post and core in addition to crown (D2954) for tooth #7 and tooth #8.

You asked the Plan to pre-approve the prefabricated posts and cores. You say that these services should be approved because they are necessary.The Plan denied your request. The Plan says you had this same procedure for teeth #7 and #8 in January of 2020, which is less than 60 months prior to this request. This service can only be covered once every 60 months for each tooth.

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 items/services are requested in a frequency that is not covered under this benefit.Therefore, we decided that the Plan does not have to pre-approve a prefabricated post and core in addition to crown (D2954) for tooth #7 and tooth #8.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a bone replacement graft - retained natural tooth - first site in quadrant (D4263) and guided tissue regeneration - non-resorbable barrier, per site (includes membrane removal) (D4267).

You asked the Plan to pay for a bone replacement graft and guided tissue regeneration. You say that the services are necessary and you cannot afford them. The Plan denied your request. The Plan says these services are not covered under your dental 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 pay for a bone replacement graft - retained natural tooth - first site in quadrant (D4263) and guided tissue regeneration - non-resorbable barrier, per site (includes membrane removal) (D4267).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an epidural steroid injection

You asked the Plan to pre-approve epidural steroid injection. You say that you are appealing this denial. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this procedure is not supported without a treatment plan showing that coverage limits will not be exceeded.

The Plan must follow Medicare rules. Medicare rules say that the information submitted by the provider must corroborate the enrollee's medical records and show that coverage criteria have been met. Medicare rules say that epidural injections may be covered under certain specific indications.

We looked at the file and Medicare rules. No medical records were submitted with this request. The Plan attempted to obtain medical records but none were provided. Without supporting medical records, you have not shown that this request meets the Medicare criteria for coverage and is otherwise medically reasonable and necessary. Based on this information, we decided that Medicare rules for coverage of lumbar epidural steroid injection have not been met. Therefore, we decided that the Plan does not have to pre-approve an epidural steroid injection
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve office visits with an out-of-network provider.

You asked the Plan to pre-approve out-of-network office visits. You say that this doctor has been your endocrinologist for several years and you weren't informed you couldn't use him when you switched plans. You say that you would not have switched insurance companies if you knew.The Plan denied your request. The Plan says in-network providers are 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 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 office visits with an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a partial upper denture (D5213) and a partial lower
denture (D5214).

You asked the Plan to pre-approve the dental services. You say that you lost your dentures. You say that you
need replacement dentures. You also say that you cannot wait 5 years for new dentures. The Plan denied your
request. The Plan says dentures are covered once in at 60-month period. The Plan also says that the frequency
limit has been reached.

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 and partial dentures are listed covered
services, the frequency limits have been reached. The record shows that the Plan paid for partial dentures that
you received on May 23, 2019. Therefore, we decided that the Plan does not have to pre-approve a partial
upper denture (D5213) and a partial lower denture (D5214).