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

We decided that the Plan does not have to pre-approvethe CPAP supplies to be provided by an out of network provider.You asked the Plan to pre-approveCPAP supplies. You say that you would like the Plan to approve you for the supplies.The Plan denied your request. The Plan says the enrollee must use an in-network supplier.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 pre-approved care.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-approvethe CPAP supplies to be provided.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Horizant ER 600mg tablets.
You asked the Plan to pre-approve Horizant. You say that the Horizant is medically necessary. The Plan denied
your request. The Plan says coverage is not available for this type of drug under the Part B Medical Benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 Horizant ER 600mg tablets.
Benefits for Horizant may be available under Medicare Part D. Contact the Plan that administers Part D
benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a FreeStyle Libre continuous glucose monitoring system.You asked the Plan to pre-approve a continuous glucose monitoring system. You say that you need a CGM to do your daily activities like go to the gym and continuously monitor your blood sugar.The Plan denied your request. The Plan says you are not insulin injection three or more times a day.The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered only when they are medically reasonable and necessary and replace a blood glucose monitor.We looked at the file and Medicare rules. You are on oral medication and therefore criteria have not been met. Based on this information, we decided that the Plan does not have to pre-approve a FreeStyle Libre continuous glucose monitoring system.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a porcelain crown to be provided. You asked the Plan to pre-approve the crown. You say that your teeth broke due to an accident. You also say that you need this procedure because you cannot chew food well and it is affecting your health.The Plan denied your request. The Plan says this service is not covered by the MA plan, in which you are enrolled.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 porcelain crown to be provided.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve implantation of the Inspire airway device.You asked the Plan to pre-approve Inspire. You say that you feel this procedure is medically necessary to treat your condition.The Plan denied your request. The Plan says the denial of authorization for these services is correct, because the Inspire procedure is not covered by Medicare at this time.The Plan must follow Medicare rules. Medicare rules say that the Inspire procedure is not considered medically necessary and is not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Inspire have not been met.Therefore, we decided that the Plan does not have to pre-approve implantation of the Inspire airway device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 10 additional non-emergency transportation trips to be provided. You asked the Plan to pre-approve the 10 additional trips. You say that you would like to appeal the denial for extra transportation. The Plan denied your request. The Plan says the enrollee has utilized all 6 one way trips and the benefits are exhausted for the year. 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 6 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 the 10 additional trips. Therefore, we decided that the Plan does not have to pre-approve10 additional non-emergency transportation trips to be provided.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a prefabricated post and core in addition to crown and endodontic therapy to be provided. You asked the Plan to pre-approve the prefabricated post and core and endodontic therapy. You say that the dental surgery should be covered due to decay of your tooth. You also say that you are a diabetic and need to be able to eat. The Plan denied your request. The Plan says these services are not covered benefits by the plan.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 prefabricated post and core in addition to crown and endodontic therapy to be provided.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by out of network provider. You asked the Plan to pre-approve office consultations and treatment. You say that you have had terrible luck with pain clinics. You say that you trust the out of network provider and would like to have them handle this issue. The Plan denied your request. The Plan says there are in-network providers available to perform the services that are needed.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 pre-approved care.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 medical services to be provided by out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a porcelain crown (D2740) for teeth # 7 and 8.You asked the Plan to pre-approve the dental services. The Plan denied your request. The Plan says that the documentation submitted failed to show that the requested services are 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 dental services 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 dental services. Our reviewer says that the requested dental services are not medically necessary. Our physician reviewer found the x-rays provided do not show significant breakdown of teeth # 7 and 8. Therefore, the reviewer found that the crown requested for teeth # 7 and 8 are not 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 dental services have not been met.Therefore, we decided that the Plan does not have to pre-approve a porcelain crown (D2740) for teeth # 7 and 8.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Magnetic Resonance Imaging (MRI) of the Lumbar Spine (72148).
You asked the Plan to pre-approve the MRI. You say that the MRI is necessary because you have ongoing back pain. The Plan denied your request. The Plan says the documents provided do not substantiate that the MRI is medically 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 reviewer says that coverage criteria has not been met. Our physician reviewer found based on the medical records provided a lumbar spine MRI is not medically reasonable and 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 MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve Magnetic Resonance Imaging (MRI) of the Lumbar Spine (72148).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6549.
You asked the Plan to pre-approve the compression stockings. You say that you get blood clots in your legs and the stockings are medically necessary. The Plan denied your request. The Plan says gradient compression stockings A6549 are non-covered because they do not meet the statutory definition of a surgical dressing.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are noncovered because they do not meet the statutory definition of a surgical dressing. Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6549.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Diabetic Test Strips (A4253). You asked the Plan to pre-approve the test strips.. You say that the additional test strips are medically necessary.The Plan denied your request. The Plan says the allowable amount of test strips has already been approved.The Plan must follow Medicare rules. Medicare rules say that limits test strips to six (6) boxes every three (3) months. during a year. The maximum allowable amount was already approved by the plan.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the test strips. have not been met.Therefore, we decided that the Plan does not have to pre-approve Diabetic Test Strips (A4253).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power scooter.You asked the Plan to pre-approve a power scooter. You say that you have an acre of land that you need to keep clean.The Plan denied your request. The Plan says you do not meet criteria for a power scooter.The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home.Therefore, we decided that the Plan does not have to pre-approve a power scooter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea Group 2 power wheelchair to be provided by an out of network provider.You asked the Plan to pre-approvea power wheelchair and accessories. You say that you do not want to use in-network providerNorco.The Plan denied your request. The Plan says there are in-network providers that can provide the requested power wheelchair.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 pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the itemsatissue in this appeal. We found no exception that would require the Plan to pre-approve these items.Therefore, we decided that the Plan does not have to pre-approvea Group 2 power wheelchair to be provided.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a maxillary partial denture with a flexible base (D5225),
and a mandibular partial denture with a flexible base (D5226) to be provided by your doctor.
You asked the Plan to pre-approve the dental services. The Plan denied your request. The Plan says dentures
with a flexible base are not covered services.
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, partial dentures with flexible bases are
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a
maxillary partial denture with a flexible base (D5225), and a mandibular partial denture with a flexible base
(D5226) to be provided by your doctor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Glucerna.
You asked the Plan to pre-approve Glucerna. The Plan denied your request. The Plan says that enteral nutrition
products that are administered orally are not covered.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation.
The items you asked the Plan to pre-approve are nutritional supplements. Therefore, we decided that the Plan
does not have to pre-approve Glucerna.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out of network specialist.You asked the Plan to pre-approve the office visit. You say that you need to see a bone tumor specialist in your area before you have knee surgery. The Plan denied your request. The Plan says you have received authorization to see an Orthopedic Oncologist who is closest to your home.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that your PCP will coordinate the rest of the covered services you receive. We looked at your request, the file and Medicare rules. Based on this information, we find that coverage criteria for the office visit have not been met. Specifically, the record indicates that you have received approval to see the closest Orthopedic Oncologist to you. Additionally, the record indicates that your PCP and orthopedic surgeon would like you to be seen by the approved provider.  Therefore, we find that the Plan does not have to pre-approve the office visit to be provided by a different Orthopedic Oncologist. Therefore, we decided that the Plan does not have to pre-approve the medical services to be provided by an out of network specialist.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a wig. You asked the Plan to pre-approve a wig. You say that you have a medical condition and the cost of a wig is too much for your fixed income.The Plan denied your request. The Plan says wigs are not covered by Medicare or the Plan. 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. Medicare rules say that a cranial prosthesis is statutorily excluded. Therefore, we decided that the Plan does not have to pre-approve a wig.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the allograft portion of the Spinal Surgery.
You asked the Plan to pre-approve the allograft portion. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.
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 allograft portion. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has neck and arm pain. The requested bone morphogenetic protein remains experimental for use in the cervical spine. High complications and airway problems have been reported. The FDA has issued a warning against bone morphogenetic protein use in the neck. Therefore, the enrollee does not meet criteria for the requested 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 allograft portion have not been met. Therefore, we decided that the Plan does not have to pre-approve the allograft portion of the Spinal Surgery.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not haveto pre-approve additional hours of neuropsychological testing services.You asked the Plan to pre-approve the additional hours. You say that this is medically necessary.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 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 additional hours. Our reviewer says that the requested additional hours are not considered medically reasonable and necessary in this case. Our physician reviewer found you do not meet the criteria for 8 hours psychological testing as this is not delineated in the LCD noted above, as this is considered excessive. Therefore, it is not medically necessary or reasonable to have 8 hours of psychological testing as outlined as is not delineated in the LCD.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 additional hours have not been met.Therefore, we decided that the Plan does not have to pre-approve additional hours of neuropsychological testing services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Supartz injections.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 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the submitted records show that you have left knee pain related to osteoarthritis. The initial visit note dated October 22, 2019 does not show that you have tried and failed at least three months of conservative treatment. The note was altered with a change indicating conservative treatment was tried and failed, but there is insufficient credible medical documentation to show this. The requested Supartz is therefore not reasonable or medically necessary at this time.
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 Supartz injections.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea shower chair.You asked the Plan to pre-approvea shower chair. You say that you are a diabetic and are currently in a wheelchair. You say that you need the shower chair because you keep falling in the shower.The Plan denied your request. The Plan says this item is not a covered benefit.The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item.Therefore, we decided that the Plan does not have to pre-approvea shower chair.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa.You asked the Plan to pre-approve Euflexxa. The Plan denied your request. The Plan says there is no evidence that the enrollee has had previous treatment, a contraindication, or intolerance to Orthovisc and Monovisc.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 Euflexxa. Our physician reviewer found that the enrollee has pain related to osteoarthritis of both knees, confirmed with x-rays. The Plan requires a trial of drugs Orthovisc and Monovisc first before they will approve the requested drug, Euflexxa. The provided medical records do not indicate that the enrollee has tried and failed the required drugs. The medical records provided do not indicate that the Plan's required drugs would likely be less effective, 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 Euflexxa have not been met. Therefore, we decided that the Plan does not have to pre-approve Euflexxa.