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

We decided that the Plan does not have to pre-approve a new mandibular partial denture (D5214).

You asked the Plan to pre-approve the partial denture. You say that you need to have your current denture replaced as it was made improperly and digs into your gums causing pain. The Plan denied your request. The Plan says dentures are not covered by Medicare and can only be covered by the Plan's supplemental dental benefit once per arch per 60 months. Because the Plan paid for this same service a year ago, a replacement cannot be covered. However, the Plan has stated that they are opening a separate inquiry into your quality-of-care complaint.

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, a second denture within 60 months is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a new mandibular partial denture (D5214).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a genicular nerve block for the enrollee.

You asked the Plan to pre-approve the block. You say that this is medically necessary. The Plan denied your request. The Plan says this is considered experimental, investigational, or unproven.

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 block. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this procedure is considered experimental/investigational and is the subject of on-going clinical trials. Therefore, the procedure is considered not medically reasonable or necessary. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the block have not been met. Therefore, we decided that the Plan does not have to pre-approve a genicular nerve block for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 2 power wheelchair (PWC).

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 medically necessary.

The Plan must follow Medicare rules. Medicare rules say that a PWC is covered when specific criteria are 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 these services. Our reviewer says that the criteria for coverage are not met. Our physician reviewer found the submitted records do not show that the enrollee is at high risk for development of a pressure ulcer, utilizes intermittent catheterization for bladder management, or needs a power seating system to manage increased tone or spasticity. He does not require other types of proportional input devices or non-proportional input devices. He does not need to operate three or more powered seating actuators through the drive control. The criteria for coverage are not met and the Group 2 PWC is therefore 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 a Group 2 power wheelchair (PWC).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that the enrollee needs an IRF admission. The Plan denied your request. The Plan says the enrollee can safely receive the necessary services in other settings.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found 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. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 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 acute inpatient rehabilitation facility (IRF) admission and services.
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 SNF care. You say that SNF care is medically necessary. The Plan denied your request. The Plan says rules for SNF care have not been met.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the beneficiary is a 60-year-old female with diabetes, obesity and respiratory failure. While there are identifiable skilled therapy service needs, there are no identifiable skilled nursing service needs. In addition, the beneficiary does not require skilled nursing or therapy services on a daily basis and does 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 SNF care 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary. The Plan denied your request. The Plan says rules for IRF care have not been met.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee was admitted to the acute care hospital for a heart condition. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. Finally, 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental services to be provided by an out of network provider.

You asked the Plan to pre-approve dental services. You say that you require services from a dental specialist. The Plan denied your request. The Plan says there are available contracted providers that may render the service 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 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 dental services to be provided by an out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve payment for oxygen equipment (E0431, E1390).

You asked the Plan to pre-approve payment for oxygen equipment. You say that you need these items. The
Plan denied your request. The Plan says additional payment cannot be made after 36 months.

The Plan must follow Medicare rules. Medicare rules say that reimbursement for oxygen equipment is limited
to 36 monthly rental payments. The supplier who provided the equipment during the 36th rental month is
required to continue to provide the equipment, accessories, contents (if applicable), maintenance, and repair of
the oxygen equipment during the 5-year reasonable useful lifetime of the equipment.

We looked at the file and Medicare rules. The record shows that you have had the equipment at issue more than 36 months ago. No further payment can be made for this equipment. The Plan has confirmed that the supplier will continue to provide this equipment in accordance with Medicare rules. Based on this information, we decided that Medicare rules for coverage of oxygen equipment have not been met. Therefore, we decided that the Plan does not have to pre-approve payment for oxygen equipment (E0431, E1390).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.

You asked the Plan to pre-approve the LTACH services. You say that the enrollee is ready for discharge from
the hospital. The Plan denied your request. The Plan says there is no documentation that the enrollee will
benefit from and improve with LTACH management.

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 review indicates that the enrollee
does not require services at the LTACH that are not available at the acute care hospital where the enrollee 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. The requested LTACH services are not
medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be
furnished safely and effectively only on an inpatient basis.

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 LTACH services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion of an interspinous spacer device (Vertiflex).

You asked the Plan to pre-approve Vertiflex. You say that you are in chronic severe pain. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because Vertflex has not been shown to be as safe and effective as the standard of care for decompression.

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. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental. More research is needed to show its safety and efficacy. Open laminectomy is the gold standard procedure for spinal stenosis decompression. 

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 have not been met. Therefore, we decided that the Plan does not have to pre-approve insertion of an interspinous spacer device (Vertiflex).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the therapeutic continuous glucose monitor (K0553).

You asked the Plan to pre-approve the therapeutic continuous glucose monitor. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the member does not meet coverage criteria for the requested supply.

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. Based on this information, we decided that Medicare rules for coverage of the therapeutic continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve the therapeutic continuous glucose monitor (K0553).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevator for a wheelchair.

You asked the Plan to pre-approve the item. You say that this is medically necessary. The Plan denied your request. The Plan says this does not serve a primarily medical purpose.

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 elevator for a wheelchair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a maxillary immediate denture, alveoloplasty in conjunction with extractions, and 9 surgical extractions.

You asked the Plan to pre-approve the maxillary immediate denture, alveoloplasty, and extractions. You say that these services are necessary. The Plan denied your request. The Plan says the maxillary immediate denture and alveoloplasty in conjunction with extractions are not covered benefits. The Plan also says that your contract only covers one tooth extraction per year, which has already been approved.

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 maxillary immediate denture and alveoloplasty in conjunction with extractions are not among those covered under this benefit. The contract says that extraction is limited to one procedure per year. The record shows that one surgical extraction was approved for coverage on February 10, 2021, and your extraction benefit has been exhausted. Therefore, we decided that the Plan does not have to pre-approve a maxillary immediate denture, alveoloplasty in conjunction with extractions, and 9 surgical extractions.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary. The Plan denied your request. The Plan says rules for IRF care have not been met and lower level of care would be acceptable.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the patient was admitted to an acute care hospital for peripheral vascular disease. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. In addition, 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated (D7210) and panoramic radiographic image (D0330) provided November 23, 2020.

You asked the Plan to pay for the tooth extractions and panoramic x-rays. You say that the services were medically necessary. The Plan denied your request. The Plan says the dental provider has opted out of Medicare and therefore services are not covered.

The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. 

The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated (D7210) and panoramic radiographic image (D0330) provided November 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a cone beam image capture (D0364) and two surgical
implant placements (D6010).

You asked the Plan to pre-approve the dental services. You say that these are necessary services required to
help hold your dentures in place. The Plan denied your request. The Plan says these services are not covered by
Medicare or by the Plan's supplemental dental 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 a
cone beam image capture (D0364) and two surgical implant placements (D6010).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Breo Ellipta.

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 Breo Ellipta.

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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve office services to be provided by an OON provider.

You asked the Plan to pre-approve office services. You say that your oncologist recommended this provider as
one of the best breast surgeons in the area. The Plan denied your request. The Plan says the denial of
authorization for these services is correct, because this provider is out-of-network with the Plan, and you can be
treated by an in-network specialist.

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 services to be provided by an OON provider.