Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 6 physical therapy visits. You asked the Plan to pre-approve the physical therapy visits. You say that physical therapy will help the member to strengthen muscles. The Plan denied your request. The Plan says the member does not meet coverage criteria as they do not appear to have the potential to make ongoing improvements. The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 physical therapy visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found The member does not require ongoing skilled therapy or maintenance therapy for this condition beyond what was already approved by the health plan. The request for additional therapy is not medically necessary to maintain or improve the member's condition.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 physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 6 physical therapy visits
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve power operated vehicle, group 1 standard, patient weight capacity up to and including 300 pounds (CPT Code K0800). You asked the Plan to pre-approve the DME. You say that you are in need of a smaller scooter that is foldable or collapsible because the current one you have is way too big.The Plan denied your request. The Plan says the Medicare rules have not been met. The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the DME have not been met. You were evaluated on October 23, 2019 by DME Consulting Group. Based on the report, you can walk short distances in your home using a walker. The report also states you have a group 2 powered wheelchair that was provided to you in 2014and is still in good condition but you are not using it. The report states you want a scooter that you can use in the community because you can't always find a powered scooter at the grocery store or mall. Based on the report, a powered operated vehicle (scooter) is not medically necessary because it is not the most appropriate mobility device for you at this time as you are using a walker for short distances inside your home and have a powered wheelchair which is in good condition.Therefore, we decided that the Plan does not have to pre-approve power operated vehicle, group 1 standard, patient weight capacity up to and including 300 pounds (CPT Code K0800).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a right L4-5 transforaminal epidural steroid injection (64483).
You asked the Plan to pre-approve a right L4-5 transforaminal epidural steroid injection (64483). You say that the requested epidural steroid injection is medically necessary. The Plan denied your request. The Plan says the requested epidural steroid injection does not meet criteria.
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 a right L4-5 transforaminal epidural steroid injection (64483). Our reviewer says that the requested epidural steroid injection does not meet criteria. Our physician reviewer found this enrollee has chronic low back pain that radiates to his Right Leg. He had an transforminal epidural steroid injection which provided 80% relief. After 2 months the request was made to repeat the injection. The requirement is that the injection provides 2.5 to 3 months of relief which was not met. Therefore, the requested injection is deemed 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 a right L4-5 transforaminal epidural steroid injection (64483) have not been met. Therefore, we decided that the Plan does not have to pre-approve a right L4-5 transforaminal epidural steroid injection (64483).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health aide services for the enrollee.
You asked the Plan to pre-approve home health aide services. You say that the enrollee is ill and has a lot of health issues. The Plan denied your request. The Plan says the health aide services are not supporting a skilled need being taken care of by a nurse.
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. 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 home health aide services. Our physician reviewer found that the enrollee has a history of dementia, diabetes, neuropathy, depression, hypertension, and incontinence. She had been receiving home health services to assist with activities of daily living, including grooming, bathing, dressing, toileting, and mobility. She has not been receiving home health nursing services. Her medical conditions have been stable and there are no recent hospitalizations. The enrollee is not receiving skilled nursing and skilled therapy services. The home health aide services are not reasonable and necessary to the treatment of the enrollee's illness or injury by the skilled professional staff. Her needs are custodial in nature.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home health aide services have not been met. Therefore, we decided that the Plan does not have to pre-approve home health aide services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve prostatic artery embolization.
You asked the Plan to pre-approve prostatic artery embolization. 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 follows Medicare rules. Medicare rules say that therapeutic embolization is only covered for certain 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 prostatic artery embolization. Our reviewer says that the documentation does not support that the requested services are medically reasonable or necessary. Our physician reviewer found you have benign prostatic hyperplasia and lower urinary tract symptoms. You underwent prostatic artery embolization of the prostate in 2015 but apparently remained obstructed and required removal of a bladder stone in 2017. The documentation shows that your nocturia has recently worsened. The documentation does not support that you require prostatic artery embolization to reduce tumor vascularity preoperatively, to reduce tumor bulk in inoperable cases, or for palliate specific symptoms. Therefore, you do 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 prostatic artery embolization have not been met. Therefore, we decided that the Plan does not have to pre-approve prostatic artery embolization.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveplacement of a Superion interspinous spacer device.You asked the Planto pre-approvethe Superion device. You say that this procedure is necessary and should be approved.The Plandenied your request. The Plansaysthere is insufficient evidence to support that this procedure is reasonable and 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 Superion device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the requested spacer remains experimental at this time. More research is needed.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 Superion device have not been met.Therefore, we decided that the Plandoes not haveto pre-approveplacement of a Superion interspinous spacer device.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ESI (64483).
You asked the Plan to pre-approve the ESI. You say that the ESI are medically necessary. The Plan denied your request. The Plan says there is no record of conservative therapy and the member did not experience relief from the previous ESI.
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 ESI. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the prior ESI did not provide meaningful pain relief and there is not adequate documentation of conservative therapy that has been tried and failed. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the ESI have not been met. Therefore, we decided that the Plan does not have to pre-approve ESI (64483).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve eyelid blepharoplasty for the enrollee.
You asked the Plan to pre-approve eyelid blepharoplasty. 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 follows Medicare rules. Medicare rules say that lower lid blepharoplasty is covered for certain 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 eyelid blepharoplasty. Our reviewer says that the documentation does not support that the requested services are medically reasonable or necessary. Our physician reviewer found the enrollee is bothered by bags under the eyes. The enrollee is diagnosed with infraorbital fat prolapse. No functional impairment was documented directly related to the enrollee's lower eyelid tissue. As photographs were not provided and that no functional impairment was noted directly related to lower eyelid tissue, the requested lower blepharoplasty does not satisfy Medicare medically necessary criteria. 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 eyelid blepharoplasty have not been met. Therefore, we decided that the Plan does not have to pre-approve eyelid blepharoplasty for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CT Scan of the abdomen (74174). You asked the Plan to pre-approve the CT Scan. You say that the CT Scan is medically necessary. The Plan denied your request. The Plan says the documentation provided does not show a need for this test.The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the CT Scan. Our reviewer says that the member does not meet Medicare coverage criteria for the CT Scan. Our physician reviewer found in this setting and assessment of abdominal and pelvic arterial size and architecture by way of CT angiography is standard accepted practice and medically necessary to determine feasibility of the TAVR procedure to be performed via femoral access. This would not be able to be accomplished with an abd/pelvis CT scan without angiography. Abdominal/pelvic CT scan without angiography is not medically necessary.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the CT Scan have not been met. Therefore, we decided that the Plan does not have to pre-approve CT Scan of the abdomen (74174).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pain consultation, and treatment to be provided by an out of network provider.
You asked the Plan to pre-approve the physician services. You say that you have chronic pain related to your cerebral palsy. You say that you have seen various specialists. You say that doctors are confused on how to come up with a proper treatment plan. The Plan denied your request. The Plan says the requested services can be provided in network. The Plan also says the services are not emergent.
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 a pain consultation, and treatment 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-approvefoot orthotics.You asked the Plan to pre-approvefoot orthotics. You say that the enrollee needs orthotics for foot and ankle pain.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 the enrolleedoesnot suffer from diabetic foot disease and doesnot wear a leg brace. Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of orthotics for theircondition.Therefore, we decided that the Plan does not have to pre-approvefoot orthotics.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the ophthalmology evaluation to be provided by out of network provider.You asked the Plan to pre-approve the vision care. You say that you need a cornea transplant done in a hospital setting. You say that you have flat lined in the past in outpatient facilities and clinics. You say that you keep getting referred to ophthalmologists that are not able to do a cornea transplant in a hospital setting. You also say that you have had surgery with the physician in the past.The Plan denied your request. The Plan says there are in network providers available to provide the requested vision care services.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and 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. The record shows that you have been approved to see the physician for an ophthalmology evaluation. 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 ophthalmology evaluation to be provided by out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral at the in-network rate.You asked the Plan to pre-approve these services. You say that you prefer to see this provider.The Plan denied your request. The Plan says the services are available from network providers at the in-network rate.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 50% of the Medicare allowed amount for each out-of-network specialist visit for Medicare-covered services. The requested provider is not a network provider with the Plan. If you choose to receive services from this provider, you will be asked to pay 50% of the Medicare allowed amount for these services. These services fall within the out-of-network specialist visit for Medicare-covered 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. The Plan has network providers from which you may receive services at the in-network rate. Therefore, we decided that the Plan does not have to pre-approve a referral at the in-network rate.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the pontic and retainer crown.You asked the Plan to pre-approve the pontic and retainer crown. You say that you want to appeal the denial.The Plan denied your request. The Plan says the criteria for coverage has not been met.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the pontic and retainer crown when the services are medically necessary and reasonable. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the pontic and retainer crown. Our reviewer says that the criteria for coverage has not been met. Our reviewer says that there are multiple missing mandibular posterior teeth.Our physician reviewer says that coverage for a fixed bridge is limited to the replacement of a maxillary anterior tooth or two missing mandibular anterior teeth.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the pontic and retainer crown have not been met.Therefore, we decided that the Plan does not have to pre-approve the pontic and retainer crown.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CT Scan of the abdomen and pelvis (74176). You asked the Plan to pre-approve the CT Scan. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says there is insufficient clinical information to approve the requested study. The Plan must follow Medicare rules. Medicare rules say that Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the CT Scan have not been met. The record indicates that the Plan made multiple attempts to obtain the required clinical information. There is insufficient documentation to determine whether the requested study is reasonable and necessary. Therefore, we decided that the Plan does not have to pre-approve a CT Scan of the abdomen and pelvis (74176).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Myrbetriq tablets.You asked the Plan to pre-approve self-administered drugs. You say that this drug is the best choice for the enrollee.The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because this drug is not covered by Medicare Part B and the Plan does not administer the enrollee's Medicare Part D prescription drug benefits.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 Myrbetriq tablets.Benefits for self-administered drugs 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Relistor.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 a covered benefit.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 Relistor.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: Supplemental Benefit
Decision: Unfavorable

Wedecided that the Plan does not have to pre-approvenon-emergency medical transportation for your medical appointments.You asked the Plan to pre-approvethe non-emergency medical transportation. You say that you live over twenty miles from the provider where you have your doctor's appointments. You say that family members have had to take off from work to take you to the doctor's appointments and you believe the Plan should provide coverage for transportation.The Plan denied your request. The Plan says non-emergency transportation is not a covered benefit with Medicare or with the Plan.The Plan must follow Medicare rules. Medicare does not cover transport in a vehicle that is not an ambulance. The Plan follows the same rule. We looked at your request, the records in the case file, and the rules.The Plan does not offer a non-emergency medical transportation benefit and Medicare does not provide coverage for non-emergency transportation.Based on this information, we decided that the Medicare rules for coverage of the non-emergency medical transportation have not been met.Therefore, we decided that the Plan does not have to pre-approvenon-emergency medical transportation for your medical appointments.