Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a powered seat cushion (E2610) for the enrollee.
You asked the Plan to pre-approve the cushion. You say that this is medically necessary. The Plan denied your
request. The Plan says this is not primarily medical in nature.
The Plan must follow Medicare rules. The rules say that the effectiveness of a powered seat cushion (E2610)
has not been established.
Medicare does not consider this request to be medically necessary. Based on this information, we decided that
Medicare rules for coverage of the cushion have not been met. Therefore, we decided that the Plan does not
have to pre-approve a powered seat cushion (E2610) for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the physical therapy visits.

You asked the Plan to waive the copayments for the physical therapy visits. You say that the insurance plan should cover this in full because the physical therapy will save the insurance money by preventing orthopedic surgery. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 copayment for physical therapy at an in-network outpatient hospital.

You have been asked to pay a $20 copayment for each of the physical therapy visits. The physical therapy visits fall within the "Outpatient rehabilitation services" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for the physical therapy visits.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the remote monitoring of wireless pressure sensor in lung artery Cardio Micro-Electro-Mechanical Systems (MEMS) device (93264).
You asked the Plan to pre-approve the CardioMEMS device. You say that this service is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the efficacy of the CardioMEMs device is uncertain at this time and not recommended as treatment.
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 CardioMEMS device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the device should still be considered experimental or investigational. 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 CardioMEMS device have not been met. Therefore, we decided that the Plan does not have to pre-approve the remote monitoring of wireless pressure sensor in lung artery Cardio Micro-Electro-Mechanical Systems (MEMS) device (93264).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lower partial denture (D5214).
You asked the Plan to pre-approve the dental item. You say that you do not want to pay any amount. The Plan denied your request. The Plan says 1 lower partial denture is covered every 5 years. The Plan also says that the frequency limited 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, the frequency limit of 1 lower partial denture every 5 plan years has been reached. The record shows that the Plan paid for a lower partial denture that you received on October 23, 2017. Therefore, we decided that the Plan does not have to pre-approve a lower partial denture (D5214).
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve a tertiary-level referral to a dermatologist for the enrollee.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says that tertiary care requests will be sent to a community-level provider when the service can be rendered by community-level specialists.
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 referral. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found a tertiary level referral is needed due to the chronic nature of the itchy disorder. The disorder is resistant to the first-line treatments. 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 referral have been met. Therefore, we decided that the Plan has to pre-approve a tertiary-level referral to a dermatologist for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the osteogenesis stimulator (E0760).
You asked the Plan to pre-approve osteogenesis stimulator. You say that this device is necessary to expedite healing. The Plan denied your request. The Plan says this service does not meet medical necessity criteria.
The Plan must follow Medicare rules. The rules say that an electrical bone stimulator is covered for nonunion of long bone fractures. Nonunion of long bone fractures is considered to exist only when serial radiographs have confirmed that fracture healing has ceased for 3 or more months prior to starting treatment with the electrical bone growth stimulator. Serial radiographs must include a minimum of 2 sets of radiographs separated by a minimum of 90 days. 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 osteogenesis stimulator. Our reviewer says that the service is not medically necessary for the enrollee. Our physician reviewer found the review indicates that the member's surgery did not occur nine months ago, she did not have a long bone fracture, or congenital pseudarthrosis, and had no evidence of failed fusion. Therefore, the criteria for an electrical bone growth stimulator has not been met. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of osteogenesis stimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve the osteogenesis stimulator (E0760).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Linzess.

You asked the Plan to pre-approve Linzess. You say that this medication works well for the enrollee and there are no alternatives. The Plan denied your request. The Plan says coverage of this medication is the responsibility of the enrollee's prescription drug plan.

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 Linzess.

Benefits for Linzess 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 the pneumatic compression device for arterial insufficiency (E0675).

You asked the Plan to pre-approve the pneumatic compression device for arterial insufficiency. You say that this device is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the enrollee does not have an approved diagnosis for this pneumatic compression device.

The Plan must follow Medicare rules. The rules state that this type of pump is not covered. The rules say there is not enough proof that this kind of pump helps for the enrollee's condition. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the pneumatic compression device for arterial insufficiency have been met. Therefore, we decided that the Plan does not have to pre-approve the pneumatic compression device for arterial insufficiency (E0675).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc.

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 pain related to bilateral knee osteoarthritis, confirmed on imaging studies. She has not tried and failed the Plan's required drugs of Orthovisc and Monovisc. The records do not show that the required drugs would be contraindicated or less effective; therefore, the Synvisc 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 Synvisc.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the porcelain crown (D2740) for tooth # 21.

You asked the Plan to pre-approve the dental service. You say that the service is necessary. The Plan denied your request. The Plan says porcelain crown is not listed as a covered service.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the porcelain crown (D2740) for tooth # 21.
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 you need these inserts due to your condition. 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: 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 these services are medically necessary. The Plan denied your request. The Plan says that the information submitted does not show that there is a daily need for prolonged skilled nursing services.

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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex surgery.

You asked the Plan to pre-approve Vertiflex surgery. You say that the surgery is medically necessary. The Plan denied your request. The Plan says Verftiflex surgery is not medically necessary and the surgery is considered experimental/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 Vertiflex surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the spacer device with Vertiflex surgery remains experimental. More research is needed to show safety and efficacy of the device. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Vertiflex surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex surgery.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Freestyle Libre.
You asked the Plan to pre-approve Freestyle Libre. You say that you would like reconsideration because you
take 3 medications to avoid injections. The Plan denied your request. The Plan says prior authorization criteria
have not been met.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically
reasonable 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 testing results.
We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least
three daily injections and require frequent self-adjustment of insulin dosage based on the blood glucose testing
results. Based on this information, we decided that Medicare rules for coverage of Freestyle Libre have not
been met. Therefore, we decided that the Plan does not have to pre-approve the Freestyle Libre.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the removal of torus palatinus (D7472) and the removal of torus mandibularis (D7473).

You asked the Plan to pre-approve the dental services. You say that your mouth is in bad shape. You say that you were born with abnormal bone structure. You say that you were advised that you needed the abnormal bones removed in order to get dentures. You also say that you need help to get this procedure done. The Plan denied your request. The Plan says removal of torus palatinus is not listed as a covered service. The Plan says that removal of torus mandibularis is not listed as a covered service. The Plan also says that any dental services not listed in the Evidence of Coverage are 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. The Evidence of Coverage clearly states that any services not listed are not covered. Therefore, we decided that the Plan does not have to pre-approve the removal of torus palatinus (D7472) and the removal of torus mandibularis (D7473).
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 these services are medically necessary. The Plan denied your request. The Plan says that you do not require this level of care.

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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM).

You asked the Plan to pre-approve a Freestyle Libre CGM. You say that the enrollee needs this device. The Plan denied your request. The Plan says the criteria for coverage have not been met.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable 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 testing results. 

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of a Freestyle Libre CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xtampza ER 9MG capsule, for the enrollee.

You asked the Plan to pre-approve the medication. You say that you are requesting review of denial of services. The Plan denied your request. The Plan says the statute provides Part B coverage for: blood clotting factors, immunosuppressive drugs (e.g.- to prevent transplant rejection), erythropoietin for kidney dialysis patients, certain oral anti-cancer drugs, and anti-emetics used in certain situations. The Plan states the requested drug is intended for patient 'self-administration' and does not meet the Medicare criteria for Part B coverage. 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 Xtampza ER 9MG capsule, for the enrollee.

Benefits for the medication 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: 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 LTACH care is medically necessary. The Plan denied your request. The Plan says rules for LTACH care have not been met.

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. Our physician reviewer found there is no documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. 

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 Diltiazem.

You asked the Plan to pre-approve Diltiazem. You say that the enrollee has been on this medication and stopping or charging it would be hazardous. The Plan denied your request. The Plan says coverage of this medication is the responsibility of the enrollee's prescription drug plan.

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 Diltiazem.

Benefits for Diltiazem 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an additional 280 routine transportation trips.

You asked the Plan to pre-approve an additional 280 routine transportation trips. You say that you need more trips to get to dialysis appointments three times a week. The Plan denied your request. The Plan says additional trips are 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 42 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 an additional 280 routine transportation trips.