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

We decided that the Plan does not have to pre-approvea  spacer for "the beneficiary".You asked the Plan to pre-approvethese services. You say that the services are medically necessary.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 enrollee has complaints of right-sided low back pain. She has reported symptoms of neurogenic claudication. Clinical exam findings do not evidence a focal neurologic deficit. There is imaging evidence of moderate L4/5 spinal stenosis. Evidence of long-term reasonable and/or comprehensive non-operative treatment with inadequate symptom relief has been submitted. Current evidence based medical guideline and peer reviewed literature do not fully support the spinal decompression device procedure over the 'gold standard' of lumbar laminectomy. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of this device for this enrollee's medical condition. The spacer is not reasonable or medically necessary.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pre-approvea  spacer for "the beneficiary".
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Actemra.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 Actemra.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: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve electroretinography and visual evoked potential testing.You asked the Plan to pre-approve these services. You say that the testing is needed to monitor issues of ongoing intraocular pressure.The Plan denied your request. The Plan says the services are not covered.The Plan must follow Medicare rules. The rules say that the use of ERG for either glaucoma diagnosis or management is considered investigational.We looked at the file and Medicare rules. The file shows that the services are requested for management of glaucomatic optic atrophy. Medicare does not cover these services for this diagnosis.Therefore, we decided that the Plan does not have to pre-approve electroretinography and visual evoked potential testing.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips.You asked the Plan to pre-approv the additional trips. You say that you need more rides to doctor appointments. You had to reschedule because you do not have transportation.The Plan denied your request. The Plan says this request exceeds the transportation benefit limit allowed for the 2019 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 20 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 additional trips.Therefore, we decided that the Plan does not have to pre-approve additional routine transportation trips.
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 disagree with the denial.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 a $60 copayment 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 with this provider, you will be asked to pay a $60 copayment for these services. These services fall within the out-of-network specialist visit for Medicare-covered services benefit category. This means that you will be 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 has to pre-approvethe core build-up, including any pins (D2950) and the crown, porcelain fused to high noble metal (D2750). You asked the Plan to pre-approve the core build-up (D2950) and the crown (D2750). You say that the core build-up and crown are needed due to a broken cusp. The Plan denied your request. The Plan says that the services are not 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 core build-up (D2950) and the crown (D2750) 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 core build-up (D2950) and the crown (D2750). Our reviewer says that these services are medically necessary. Our physician reviewer found the dental record and x-rays indicate that tooth #18 currently has a multi-surface restoration and a fractured cusp and due to the large restoration and fractured cusp a core build up is reasonable and necessary to provide a strong base for the crown.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 core build-up (D2950) and the crown (D2750) have been met. Therefore, we decided that the Plan has to pre-approve the core build-up, including any pins (D2950) and the crown, porcelain fused to high noble metal (D2750). If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvebrake and tote bag for wheeled walker.You asked the Plan to pre-approvethe items. You say that you are requesting review of denial of services.The Plan denied your request. The Plan says these items are not covered under Medicare or the Health 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.Therefore, we decided that the Plan does not have to pre-approvebrake and tote bag for wheeled walker.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvesurgical insertion of an interspinous process spacer for "the beneficiary".You asked the Plan to pre-approvesurgical insertion of an interspinous process spacer. You say that you would like the plan to reconsider their denial.The Plandenied 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 surgical insertion of an interspinous process spacer. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has worsening lumbar spinal stenosis with neurogenic intermittent claudication. The enrollee has received an epidural steroid injection, which did help withthe radicular pain but is still having difficulties walking any long distances and the enrollee's legs burn. The requested spacer is considered experimental. More research is needed for the requested spacer. 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 surgical insertion of an interspinous process spacer have not been met.Therefore, we decided that the Plan does not have to pre-approvesurgical insertion of aninterspinous process spacer.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea lumbar epidural injection (62323).You asked the Plan to pre-approve the lumbar epidural injection. You say that the lumbar epidural injection is medically necessary. The Plan denied your request. The Plan says the provided documentation lacks any specific strength, sensation, or reflex deficits that would indicate compromise of the L4-L5 neural structures. Additionally, there is no submission of progress notes indicating that the patient has undergone at least 4-6 weeks of conservative treatment measures to include physical therapy, ongoing home exercises prior to consideration to injection therapy.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 lumbar epidural injection. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation of conservative therapy trials.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 lumbar epidural injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a lumbar epidural injection (62323).
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pre-approve a transthoracic echocardiography (TTE) test.You asked the Plan to pre-approve TTE test. You say that you are appealing with medical records.The Plan denied your request. The Plan says that the denial of authorization for this service is correct, because the documentation submitted does not show that the enrollee has a severe heart problem.The Plan follows Medicare rules. Medicare rules say that transthoracic echocardiography (TTE) is covered for the evaluation of certain conditions, including systolic or diastolic dysfunction.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 TTE test. Our reviewer says that the enrollee meets the Medicare criteria for the requested TTE test. Our physician reviewer found the enrollee has documented coronary disease, new exertional dyspnea, ongoing hypertension, and documented concern for diastolic dysfunction. Under these circumstances an echocardiogram is medically reasonable and appropriate. Medication therapy may require adjustment based on the results of left ventricular systolic and diastolic function that is not previously documented.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of TTE test have been met.Therefore, we decided that the Plan has to pre-approvea transthoracic echocardiography (TTE) test.If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an authorization for a lumbar facet block (4493, 64494, 64495).You asked the Plan to pre-approve a lumbar facet block. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says per the clinical documentation, the member only received pain relief for two weeks.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 lumbar facet block. Our reviewer says that the requested items/services are not considered medicallyreasonable and necessary in this case. Our physician reviewer found the duration of pain relief does not meet the LCD criteria.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 lumbar facet block have not been met.he has had 2 sets of facet injections. the first set gave her 80% pain relief for 2 months. the second set gave her 60% for 2 weeks. Therefore, we decided that the Plan does not have to pre-approve an authorization for a lumbar facet block (4493, 64494, 64495).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and supplies for the enrollee.
You asked the Plan to pre-approve a CGM and supplies. You say that this is the best option for the enrollee. The Plan denied your request. The Plan says that the enrollee does not meet requirements for a CGM.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered when the above criteria have been met. We looked at the file and Medicare rules. The file indicates the enrollee is not treated by insulin injections or testing his blood glucose four or more times a day. Based on this information, we decided that Medicare rules for coverage of a CGM and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and supplies for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprovea pneumatic compression device (E0652).You asked the Plan to preapprovea pneumatic compression device. You say that the enrollee requires the device.The Plan denied your request. The Plan says the documentation did not support the 4-week trial using the basic pump that Medicare requires.The Plan follows Medicare rules.The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At leastfour weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required.
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided.Therefore, we decided that the Plan does not have to preapprovea pneumatic compression device (E0652).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.
You asked the Plan to pre-approve a shower chair. You say that it is hard for you to get in and out of the bathtub. You say that you have already fallen twice trying to get out of 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-approve a shower chair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea porcelain or ceramic crown (code D2740) and core buildup, including any pins when required (code D2950).You asked the Plan to pre-approvethe crown and core buildup. The Plan denied your request. The Plan says these services are not covered under your benefit 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-approvea porcelain or ceramic crown (code D2740) and core buildup, including any pins when required (code D2950).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea complete maxillary denture (D5110), a mandibular partial denture (D5214) to be provided by Paola Soto, DMD.You asked the Plan to pre-approvethe dental items. You saythat you dropped your dentures. You say that they cracked from the center in the roof to the teeth. You also say that you have tried to have them repaired twice.The Plan denied your request. The Plan says the frequency limit of once every 5 years 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 dentures are a covered service, the frequency limit has been reached. The record shows that you last received dentures on August 15, 2017, less than 5 years ago.Therefore, we decided that the Plan does not have to pre-approvea complete maxillary denture (D5110), a mandibular partial denture (D5214) to be provided by "the provider".
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 12 additional outpatient physical therapy visits.You asked the Plan to pre-approve the physical therapy. You say that you need physical therapy every winter to help with your condition.The Plan denied your request. The Plan says there has been little to no improvement in your condition so additional physical therapy is not medically necessary.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. 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 there is no indication at this time that residual deficits could not be addressed via a home exercise program.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 have not been met.Therefore, we decided that the Plan does not have to pre-approve12 additional outpatient physical therapy visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a semi-electric hospital bed.You asked the Plan to pre-approve a semi-electric hospital bed. You say that because of medical conditions you need a semi-electric hospital bed.The Plan denied your request. The Plan says the documentation does not support a need for frequent or immediate changes in body position.The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered medically necessary when the patient:1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or2. Requires attachments which can only be attached to a hospital bed; AND3. Requires frequent changes in body position and/or has an immediate need for a change in body position.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 semi-electric hospital bed. Our physician reviewer found records do not indicate need for frequent and/or immediate changes in body position, or need for special bed attachments.  As such, a hospital bed is not 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 a semi-electric hospital bed have not been met.Therefore, we decided that the Plan does not have to pre-approve a semi-electric hospital bed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power mobility device (PMD).
You asked the Plan to pre-approve a PMD. You say that when you had a wheelchair you had less issues. The
Plan denied your request. The Plan says that your four wheel walker with seat continues to be your most
appropriate assistive device.
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 mobility device (PMD).