Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat Euflexxa injection. 
 
You asked the Plan to pre-approve the Euflexxa injection. You say that the enrollee has received sufficient 
relief from this treatment to justify its use. The Plan denied your request. The Plan says this is only covered if it 
provides relief lasting at least six months. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Euflexxa injection. Our reviewer 
says that the requested treatment is not reasonable and necessary. Our physician reviewer found six months 
have not past since the last injection. Euflexxa injection criteria have 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 the Euflexxa injection have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a repeat Euflexxa injection.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lumbar epidural steroid injection. 
 
You asked the Plan to pre-approve the requested service. The Plan denied your request. The Plan says the 
clinical information does not include a treatment plan with the spinal levels. 
 
The Plan follows Medicare rules. Medicare rules say that lumbar epidural injections are only covered under 
certain medical 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 the requested service. Our physician 
reviewer found that the enrollee has chronic low back pain with radiation into her legs.  
 
 
She has had a prior trial of physical therapy without improvement. She is taking Gabapentin, Tramadol, 
Tylenol, and Nortriptyline for pain. The request does not specify the level(s) to be injected nor the route 
(transforaminal, interlaminar, caudal.). Therefore, the request is deemed not medically reasonable without this 
information. 
 
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 requested service have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a lumbar epidural steroid injection.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MRI, spinal canal and contents, cervical; without 
contrast material (CPT Code 72141). 
 
You asked the Plan to pre-approve the MRI. You say that the service is necessary. The Plan denied your 
request. The Plan says the service is not necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 MRI. Our physician reviewer found 
review records dated January 20, 2020, support the enrollee previously underwent an MRI of the neck. A 
detailed history of oral medication, conservative treatments, previous imaging, and plan of care pending the 
repeat MRI are not outlined in the record. Without the support of the documentation, medical necessity cannot 
be determined. 
 
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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the MRI, spinal canal and contents, cervical; without contrast material (CPT Code 72141).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the established patient office or other outpatient visit 
(99213) to be provided by an out of network (OON) provider. 
 
You asked the Plan to pre-approve the established patient office or other outpatient visit. You say that you were 
previously seen by the out of network provider and require a yearly follow-up. The Plan denied your request. 
The Plan says they have approved an in-network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the established patient office or other outpatient visit (99213) to be provided by an out of network (OON) 
provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete upper denture (D5110), a partial lower 
denture (D5214). 
 
You asked the Plan to pre-approve the dental services. You say that you lost your dentures about 4 months ago. 
You say that your gums are now sore from trying to eat and going without dentures for so long. You also say 
that you were not aware of how frequent dentures were covered. The Plan denied your request. The Plan says 
dentures are covered once every 5 plan years. 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 complete and partial dentures are 
listed as covered, the frequency limit of once every 5 plan years has been reached. The record shows that the 
Plan previously paid for the complete and partial denture that you received on June 11, 2018. Therefore, we 
decided that the Plan does not have to pre-approve a complete upper denture (D5110), a partial lower denture 
(D5214).
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 more therapy is necessary before you go home. 
The Plan denied your request. The Plan says you are receiving adequate rehab in the inpatient rehab facility. 
 
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 physician reviewer 
found that from a nursing perspective, you received oral medications and had stable vital signs. There are no 
identifiable skilled nursing service needs. Regarding rehab services, you are at an independent to supervision 
level with functional mobility. You require maximal assist with most activities of daily living. Although there 
are identifiable skilled therapy service needs, you do not require skilled nursing or therapy services on a daily 
basis. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a SNF 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an upper partial denture (D5211). 
 
You asked the Plan to pre-approve the dental service. You say that you received an implant that did not secure 
after 6 weeks. You say you were advised to get a partial denture instead. You say that you were advised the 
dentist would apply your payment for the implant to the partial denture. You also say that you want to make 
sure that the dentist is not paid twice. The Plan denied your request. The Plan says dentures are covered once 
every 5 years. 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 the partial denture is listed as a 
covered service, the frequency limit of once every 5 years has been reached. The record shows that the Plan 
previously paid for an upper partial denture that you received on October 4, 2017. Therefore, we decided that 
the Plan does not have to pre-approve an upper partial denture (D5211).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. You say that the enrollee cannot do any other medication but Prolia. 
The Plan denied your request. The Plan says the criteria have not been met. The Plan also says that the 
documentation does not show why it is medically necessary to make an exception for the enrollee. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Prolia. Our reviewer says that Prolia is 
not medically reasonable and necessary for the enrollee. Our physician reviewer found the enrollee has not 
tried and failed the required drugs. Our reviewer also found that there is no documentation provided indicating 
that the Plan's required drugs would likely be less effective and/or likely have adverse effects 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 Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission and services. 
 
You asked the Plan to pre-approve SNF services. You say that the enrollee will improve care being in a SNF. 
The Plan denied your request. The Plan says the enrollee does not require daily skilled nursing or therapy in a 
SNF setting. 
 
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 physician reviewer 
found that from a nursing perspective, the enrollee received oral medications, and had stable vital signs. There 
are no identifiable skilled nursing service needs. Regarding rehab services, the enrollee was at a moderate to 
maximal assist level with functional mobility. He required varying assist with activities of daily living. 
Although there are identifiable skilled therapy service needs, he 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, 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 a skilled nursing facility (SNF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections (64493, 64494, 64495). 
 
You asked the Plan to pre-approve facet joint injections. You say that these injections helped you in the past. 
The Plan denied your request. The Plan says previous injections did not provide adequate pain relief. 
 
The Plan must follow Medicare rules. Medicare rules say that injections may be repeated if the first injection 
results in significant pain relief (greater than 50%) for at least 3 months. 
 
We looked at the file and Medicare rules. The record shows that previous injections resulted in only 30% pain 
relief. Based on this information, we decided that Medicare rules for coverage of facet joint injections have not 
been met. Therefore, we decided that the Plan does not have to pre-approve facet joint injections (64493, 
64494, 64495).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core buildup (D2950). 
 
You asked the Plan to pre-approve core buildup (D2950). The Plan denied your request. The Plan says the 
service is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve core 
buildup (D2950).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6530. 
 
You asked the Plan to pre-approve the compression stockings. You say that you need the stockings for varicose 
veins and venous insufficiency. The Plan denied your request. The Plan says you do not have a qualifying 
wound. 
 
The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6530 
are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that 
compression bandages and gradient compression wraps are covered only when they are used as dressings over 
a qualifying wound. 
 
The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you 
do not have a medical condition for which compression stockings can be covered or paid for by Medicare. 
Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code 
A6530.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a caregiver to provide the enrollee with in-home 
custodial care. 
 
You asked the Plan to pre-approve a caregiver to provide in-home custodial care. You say that the enrollee 
needs help with activities of daily living. The Plan denied your request. The Plan says the rules for coverage 
have not been met. 
 
The Plan must follow Medicare rules. The rules say that custodial care is not covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the custodial care services have not been met. Specifically, this service is not covered by Medicare 
or the Health Plan. Therefore, we decided that the Plan does not have to pre-approve a caregiver to provide the 
enrollee with in-home custodial care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the sterile foam dressing, wound cover (A6212). 
 
You asked the Plan to pre-approve the wound care supplies. You say that you feel that it is unfair to not allow 
these dressings to be covered since a lesser dressing may allow you to degrade to stage 3 or 4. The Plan denied 
your request. The Plan says the clinical documentation does not meet Medicare's criteria for medically 
necessary and reasonable. 
 
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 wound care supplies. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found in this case, the enrollee, with a stage II coccyx ulcers measuring 3.5 x 1.5 cm and 1 
x 1 cm. No depth or drainage was noted. Previous measurements were not given. It was recently reported that 
the wounds had been improving, healed, without drainage, and no redness. There was no report of recent injury 
or debridement to the ulcers to be a qualified wound. There was no report of a need for regular foam dressing 
changes as there was no report of drainage or other factors which might warrant a foam dressing. Therefore, 
this request for such will be considered not medically necessary based on the documentation provided. 
 
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 wound care supplies have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the sterile foam dressing, wound cover (A6212).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve4 porcelain crowns (D2740),4 core build up (D2950), and 2 crown repairs (D2980).You asked the Plan to pre-approvethe dental services. You say that per the fee schedule, 2 crowns (D2750) are allowed per year.The Plan denied your request. The Plan says porcelain crowns are not listed as a covered service. The Plan says that core build up is not listed as a covered service. The Plan also says crown repair is not listed as a covered service either.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-approve4 porcelain crowns (D2740), 4 core build up (D2950), and 2 crown repairs (D2980).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a core buildup, including any pins when required 
(D2950) and endodontic therapy (D3320) for tooth #13. 
 
You asked the Plan to pre-approve the core buildup and endodontic therapy. You say that the enrollee's teeth 
have significant breakdown due to decay. You also say that cracks around the teeth are causing the enrollee to 
have sensitivity and discomfort. The Plan denied your request. The Plan says core buildup is not a covered 
benefit. The Plan also says that the endodontic therapy for tooth #13 exceeds the allowable limits. 
 
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, core buildup, including any pins when 
required is not among those covered under this benefit. The contract clearly states that endodontic therapy 
(D3320) is limited to once per permanent tooth per lifetime. The record shows that the enrollee received an 
endodontic therapy (D3320) on tooth #13 on March 11, 2020, and the enrollee's endodontic therapy benefit for 
tooth #13 has been exhausted. Therefore, we decided that the Plan does not have to pre-approve a core buildup, 
including any pins when required (D2950) and endodontic therapy (D3320) for tooth #13.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repairs to a Jazzy heavy-duty power wheelchair. 
 
You asked the Plan to pre-approve power wheelchair repairs. You say that you are appealing. The Plan denied 
your request. The Plan says the denial of authorization for these repairs is correct, because this power 
wheelchair has exceeded its reasonable useful lifetime and repairs are not cost-effective compared to providing 
a replacement power wheelchair. 
 
The Plan must follow Medicare rules. Medicare rules say that Plans may determine the reasonable useful 
lifetime of durable medical equipment (DME), but in no case can it be less than 5 years. Repairs are not 
covered in excess of the estimated cost of replacement equipment for the remaining period of medical need. 
 
We looked at the file and Medicare rules. The enrollee's power wheelchair is currently 7 years old, and 
therefore has exceeded the reasonable useful lifetime of 5 years. Furthermore, the Plan has provided an 
estimated cost of replacement that is less than the cost of the requested repairs. Based on this information, we 
decided that Medicare rules for coverage of power wheelchair repairs have not been met. Therefore, we 
decided that the Plan does not have to pre-approve repairs to a Jazzy heavy-duty power wheelchair.