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

We decided that the Plan has to pre-approvere treatment of previous root canal therapy (D3346) of tooth #10.You asked the Plan to pre-approve the retreatment of previous root canal therapy. You say that you need this service because you are in pain.The Plan denied your request. The Plan says that the service is not medically necessary. The Plan also says that the provided x-rays show that your gum (periodontal) health of your teeth is poor.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 retreatment of previous root canal therapy 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 retreatment of previous root canal therapy. Our reviewer says that the retreatment of the root canal for tooth #6 meets the criteria for coverage. Our physician reviewer found the present root canal filling does not extend beyond the post to the apex of the tooth. The bone support appears adequate. Our reviewer also found that the service is medically reasonable and necessary.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 retreatment of previous root canal therapy have been met.Therefore, we decided that the Plan has to pre-approvere treatment of previous root canal therapy (D3346) of tooth #10.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 a pontic (D6240) for tooth #6 and retainer crowns (D6750) for tooth #'s 5 and 7.
You asked the Plan to pre-approve the pontic and retainer crowns. You say that your tooth needs to be fixed because it is dangerous for you, and you barely eat because of it. The Plan denied your request. The Plan says the services are not medically necessary.
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 pontic and retainer crowns 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 pontic and retainer crowns. Our reviewer says that these services do not meet the Plan's coverage criteria. Our physician reviewer found due to the poor prognosis of a fixed bridge to replace tooth #6 and a more reasonable treatment of a removable partial denture to replace multiple teeth, the criteria for coverage for a fixed bridge 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 pontic and retainer crowns have not been met. Therefore, we decided that the Plan does not have to pre-approve a pontic (D6240) for tooth #6 and retainer crowns (D6750) for tooth #'s 5 and 7.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve CT scan of the abdomen for the enrollee.
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your request. The Plan says that no additional clinical information was submitted.
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 the scan. Our reviewer says that the requested scan is medically reasonable and necessary. Our physician reviewer found the enrollee has a history including abnormal labs where adrenal adenoma is a diagnosis to be excluded. As such a CT of the abdomen without and with IV contrast (CPT 74170) is reasonable and the best way to evaluate for such a cause of her symptoms. 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 scan have been met. Therefore, we decided that the Plan has to pre-approve CT scan of the abdomen for the enrollee.
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve laparoscopy surgery.
You asked the Plan to pre-approve bariatric surgery. You say that you are appealing with medical records. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because there is no indication that the enrollee has tried diet/exercise or has had clearance from a licensed mental health professional and dietician.
The Plan follows Medicare rules. Medicare rules say that bariatric surgical treatment of morbid obesity is only covered when certain specific clinical criteria have been 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 bariatric surgery. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested bariatric surgery. Our physician reviewer found the enrollee does not have documentation of one of the required comorbid conditions and has not had a psychological evaluation. The enrollee has severe gastroesophageal reflux disease (GERD) refractory to medication. This is not likely to improve if converted to sleeve gastrectomy and could worsen GERD for the 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 bariatric surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve laparoscopy surgery.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a mandibular bone graft for the enrollee.
You asked the Plan to pre-approve the graft. You say that this is medically necessary. The Plan denied your request. The Plan says the reason that was provided in the medical records for the requested procedure - preparation for future implants - is not considered medically necessary, and implants 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. The Plan covers the graft 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 graft. Our reviewer says that the requested graft is not medically reasonable or necessary. Our physician reviewer found the requests in this case involve replacement of failed implants that were initially placed to provide anchor support for a full denture. Medicare specifically states that treatment of structures directly supporting the teeth or for replacement of teeth are not covered services. That fact that the treatment requested is for damaged bone from infection from failed implants that were placed to replace teeth does not change the issue that the new procedures are primarily still intended to be performed to replace missing teeth. Given the provided records, there is no medical necessity under the specified provisions of Medicare. 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 graft have not been met. Therefore, we decided that the Plan does not have to pre-approve a mandibular bone graft for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.You asked the Plan to pre-approve SNF services. You say that the enrollee has been making a lot of progress, and is starting to stand and walk.The Plan denied your request. The Plan says the enrollee does not have a daily skilled need requiring a nurse or therapist.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 applythe relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF services. Our physician reviewer found that from a nursing perspective, the enrollee had stable vital signs, and your lungs were clear. There are noidentifiable skilled nursing service needs. Regarding rehab services, the enrollee is at a supervision assist level with functional mobility. She requires varying assist with activities of daily living. There are no identifiable skilled therapy service needs. She does not require skilled nursing or therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a SNF setting.We looked at this physician's review, the file, andMedicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approveskilled nursing facility (SNF) services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy services to be provided by an out of
network (OON) provider.
You asked the Plan to pre-approve the out of network physical therapy services. You say that the care needed is
medically necessary. The Plan denied your request. The Plan says there are in-network providers who can
supply the services being requested.
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
physical therapy services to be provided by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on February 18, 2020.
You asked the Plan to pay for the services. You say that the lab performed all of the tests that were ordered by the referring physician. The Plan denied your request. The Plan says Medicare says screening services with no relation to a medical diagnosis of disease for the health of the patient are not a benefit.
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 pay for the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found no provider records have been submitted for review. Therefore, there is no evidence to support that the provided service was medically necessary and reasonable to diagnose, treat or otherwise manage the enrollee's condition(s). 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 services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services provided to the enrollee on February 18, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. The Plan denied your request. The Plan says that your current needs are being met in the acute setting.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. The short-term acute care hospital can provide for all of your present inpatient care needs and you are receiving an appropriate level of care in the present setting. Continued care in the short-term acute care hospital is appropriate until you are stable to transfer to a lower level of care such as an inpatient rehabilitation facility, a sub-acute rehabilitation facility or a skilled nursing facility. Our physician reviewer found that your condition does not meet Medicare criteria for LTACH 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 the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Decitabine for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says the claims for routine costs associated with a clinical trial are not payable by the plan.
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in Original Medicare and the plan cost-sharing for the same services. In this case, you asked the Plan to pre-approve the drug as part of a clinical trial. The Plan does not cover routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have to pre-approve Decitabine for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genetic testing.
You asked the Plan to pre-approve the testing. You say that this is medically necessary. The Plan denied your request. The Plan says this is not covered without a personal history of cancer.
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 testing. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found you are concerned about developing pancreatic cancer due to a family history of the same. Genetic counseling/testing has been requested to assess your risk of developing pancreatic cancer. Such testing is not diagnostic of cancer and is not necessary to treat such cancer, should it develop. The requested testing is not shown to be medically necessary or reasonable to diagnose, treat or manage your health. 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 testing have not been met. Therefore, we decided that the Plan does not have to pre-approve genetic testing.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve TheraSkin for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says that medical studies have not proven that this procedure is safe and helpful for treatment of the enrollee's health problem.
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 the drug. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found TheraSkin usage for this enrollee will be within the standard of care, because other treatments have failed. 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 drug have been met. Therefore, we decided that the Plan has to pre-approve TheraSkin for the enrollee.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprove a pneumatic compression device (E0651).You asked the Plan to preapprove a pneumatic compression device. You say that the enrollee has lymphedema and requires the device.The Plan denied your request. The Plan says the documentation did not support the 4-week trial of conservative therapy demonstrating failed response to treatment.The Plan follows Medicare rules. The rules state that a PCD coded as E0650 or E0651 is covered for the treatment of lymphedema when at least four weeks of conservative therapy (including use of compression stockings, elevation, and exercise) have been attempted.We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, conservative therapy including compression stockings, elevation and exercise.Therefore, we decided that the Plan does not have to preapprove a pneumatic compression device (E0651).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve orthopedic services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the OON services. The Plan denied your request. The Plan says there are contract providers that can provide the 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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve orthopedic services to be provided by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Mycophenolate Mofetil.
You asked the Plan to pre-approve Mycophenolate Mofetil. You say that the enrollee has tried and failed more conservative treatments. The Plan denied your request. The Plan says immunosuppressive drugs are only covered for treatment of transplants.
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 for the enrollee's condition are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Mycophenolate Mofetil.
Benefits for Mycophenolate Mofetil 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve fibromyalgia testing.You asked the Plan to pre-approve fibromyalgia testing. 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 arenot 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 fibromyalgia testing. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that this type of test is not supported by the current guidelines and has not proven to lead to improved treatment decisions or substantially change outcomes with fibromyalgia patients. Therefore, without sufficient support made for this request, the fibromyalgia test will be considered not 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 fibromyalgia testing have not been met.Therefore, we decided that the Plan does not have to pre-approvefibromyalgia testing.