Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea referral to an out-of-network provider.You asked the Plan to pre-approvethese services. You say that you had cancer in 2013 and you need routine follow-up testing.The Plan denied your request. The Plan says the services are available from network providers.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-approvea referral to an out-of-network provider.
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 you?re disabled and have fallen from weakness 
and unable to get up. 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lumbar fusion surgery (20930, 20936, 22633, 22842, 
22853, 63030). 
 
You asked the Plan to pre-approve lumbar fusion surgery. You say that this is medically indicated. The Plan 
denied your request. The Plan says the requested surgery is unlikely to improve function. 
 
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 lumbar fusion surgery. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no documented spinal instability. There is no clear previous failure of fusion 
documented.  There are no red flags for surgery at this time. Fusion surgery is not likely to be effective in 
relieving this patient's chronic lower back pain. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of lumbar fusion surgery have not been met. Therefore, we decided that the Plan 
does not have to pre-approve lumbar fusion surgery (20930, 20936, 22633, 22842, 22853, 63030).
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Synvisc-One (J7325). 
 
You asked the Plan to pre-approve Synvisc-One. You say that you do not have step therapy requirements in 
your 2020 Plan. The Plan denied your request. The Plan says that you are required to try a different drug 
according to step therapy rules. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. Plans must disclose that Part B drugs may be subject to step therapy 
requirements in the Evidence of Coverage (EOC). The Plan's EOC does not indicate that it has implemented 
such criteria for certain Part B medications. 
 
We looked at the file and Medicare rules. The Plan has not disclosed that Part B medications are subject to step 
therapy in the EOC. Based on this information, we decided that Medicare rules for coverage of Synvisc-One 
have been met. Therefore, we decided that the Plan has to pre-approve Synvisc-One (J7325).  
 
 
 
 
 
 
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: Surgery
Decision: Favorable

We decided that the Plan has to pre-approveendovenous ablation.You asked the Plan to pre-approvethese services. You say that you disagree with the denial.The Plan denied your request. The Plan says that the services are not medically necessary.The Plan must follow Medicare rules. Medicare rules say that endovenous ablation is covered when specific criteria are met.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are medically necessary. Our physician reviewer found the submitted records contain satisfactory documentation that your left leg symptoms can be attributedto the saphenous reflux in that leg. You have documented pain limiting your daily activities that is distinct from your other co-existing conditions. There is no documentation of deep vein thrombosis (DVT). You have received prior conservative treatment without relief in symptoms. The requested endovenous ablation meets the criteria for coverage and is reasonable and 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 been met.Therefore, we decided that the Plan has to pre-approveendovenous ablation.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/orsend 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-approvea second opinion to be provided by an out of network (OON) provider.You asked the Plan to pre-approvephysician services. You say that you would like to see this doctor.The Plan denied your request. The Plan says there are in-network providers available for these 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 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-approvea second opinion to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea consultation to be provided by the requested physician.You asked the Plan to pre-approve the physician's services. The Plan denied your request. The Plan says that the plan requires the enrollee to receive care from providers who are part of the enrollee's primary care physician's (PCP) specialty network.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 contract with the Plan also says that the plan requires the enrollee to receive care from providers who are part of the enrollee's primary care physician's (PCP) specialty network.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approvea consultation tobe provided by the requested physician
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 25 additional transport trips (W6110). 
 
You asked the Plan to pre-approve the additional transport trips. You say that the additional trips are medically 
necessary. The Plan denied your request. The Plan says your benefit for routine transportation has been 
exhausted. 
 
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 Plans coverage rules apply in this 
case. The Plan covers a maximum of 50 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 routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve 25 additional transport trips (W6110).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endodontic therapy and prefabricated post and core for 
tooth #12. 
 
You asked the Plan to pre-approve endodontic therapy and prefabricated post and core for tooth #12. You say 
that you were informed you needed this treatment to correct the problem area. You say that now that insurance 
is available you should be covered with this dentist. The Plan denied your request. The Plan says the services 
remain denied. 
 
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 endodontic 
therapy when the service is medically necessary and reasonable. The prefabricated post and core are not a 
covered benefit.  
 
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 endodontic therapy for tooth #12. Our 
reviewer says that tooth #12 has been previously treated with endodontics one year prior to this claim. Our 
physician reviewer found that if treatment is needed it would be considered a re-treatment which is under a 
separate CDT code. Our reviewer says that given the request under D3220, the request cannot be considered 
medically necessary as the code submitted in not appropriate. 
 
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 endodontic therapy and prefabricated post and core for tooth #12 have not been 
met. Therefore, we decided that the Plan does not have to pre-approve endodontic therapy and prefabricated 
post and core for tooth #12.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approveintermittent limb compression device.You asked the Plan to pre-approveintermittent limb compression device. You say that you would like reconsideration because you trialed the regular leg pump device and demonstrated and increase in swelling.The Plan denied your request. The Plan says you did not fail a 4 week trial of basic lymphedema pump. The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with venous stasis ulcers. The rules also say that a four-week trial of conservative therapy demonstrating failed response to treatment with and E0650 or E0651 is required.The file does not show that you completed a 4 week trial with a basic lymphedema pump.Therefore, we decided that the Plan does not have to pre-approveintermittent limb compression device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.You asked the Plan to pre-approve foot orthotics. You say that you need this after your right knee arthroplasty.The Plan denied your request. The Plan says this item is not acovered 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 you donot suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition.Therefore, we decided that the Plan does not have to pre-approvefoot orthotics.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveEuflexxa (J7323).You asked the Plan to pre-approveEuflexxa. The Plan denied your request. The Plan says the documentation did not support the medical necessity for a step therapy exception.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 topre-approve Euflexxa. Our reviewer says that Euflexxa is not medically reasonable and necessary for the enrollee. Our physician reviewer found there is no evidence that the enrollee has previously tried the requested Euflexxa injections, or is currently under treatment with Euflexxa injections. Our reviewer found that there is no evidence that the enrollee has tried and failed the required step therapy drugs. Our physician reviewer also found that there is no indication in the submitted medical records that the Plan's required drug(s) are likely to be less effective and/or likely have adverse effects for this enrollee. Documentation did not support medical necessity for a step therapy exception.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-approveEuflexxa (J7323).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve tracheostomy cleaning brushes (A4626 x 120).

You asked the Plan to pre-approve the tracheostomy cleaning brushes. You say that the additional brushes are medically necessary. The Plan denied your request. The Plan says the amount requested exceeds the allowable amount. The plan has approved the maximum of 2 per month.

The Plan must follow Medicare rules. Medicare rules say that there is a quantity limitation of 2 per month for A4626. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the tracheostomy cleaning brushes have not been met. Therefore, we decided that the Plan does not have to pre-approve tracheostomy cleaning brushes (A4626 x 120). Note the plan has already authorized 12 cleaning brushes.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the complete upper and lower (D5110 and D5120) 
denture. 
 
You asked the Plan to pre-approve the complete upper and lower denture (D5110 and D5120). You say that 
you never received the dentures. You say that you can't fit the dentures without surgery. The Plan denied your 
request. The Plan says the service is exceeds the maximum count allowed per period. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, you also have a maximum benefit of 
one complete and upper denture every five plan years. The Plan paid for a complete upper and lower denture 
provided on May 23, 2018 which exhausted your benefit. Therefore, we decided that the Plan does not have to 
pre-approve the complete upper and lower (D5110 and D5120) denture.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence supplies. 
 
You asked the Plan to pre-approve incontinence supplies. You say that the garments are medically necessary. 
The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecontinued coverage of a Continuous Positive Air Pressure (CPAP) device (E0601).You asked the Plan to pre-approvethe CPAP machine. You say that continued coverage of the CPAP is medically necessary.The Plan denied your request. The Plan says coverage criteria has not been met.The Plan follows Medicare rules. Medicare rules say that continued use of CPAP is covered when there is Objective evidence of adherence to use of the PAP device. 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 CPAP machine. Our reviewer says that continued coverage of the CPAP machine is not medically necessary. Our physician reviewer found there is no documentation that the enrollee is consistently using the CPAP machine or that the present machine is not working and the supplier has checked it and it cannot be repaired. Available records indicate the enrollee has only been using the PAP machine 2.2% of days (2 of 90).Welooked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the CPAP machine have not been met.Therefore, we decided that the Plan does not have to pre-approvecontinued coverage of a Continuous Positive Air Pressure (CPAP) device (E0601).
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approvea referral to a tertiary-level urogynecologist.You asked the Plan to pre-approvethese services. You say that you are constantly sick.The Plan denied your request. The Plan says that the tertiary level of care is not medically necessary.The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for anitem or service, then that item or service will be covered when it is 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 these services. Our reviewer says that the tertiary level of care is medically necessary. Our physician reviewer found the submitted records show that there is evidence of mesh and suture erosion. Only a urogynecologist can provide the care you need. The Plan providers are not fellowship trained in female pelvic medicine and reconstructive surgery. The referral to the tertiary level urogynecolost is reasonable and 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 been met.Therefore, we decided that the Plan has to pre-approvea referral to a tertiary-level urogynecologist.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-approvea Negative Pressure Wound Therapy Device.You asked the Plan to pre-approvethe wound vac. You say thatthe wound vac is medically necessary.The Plan denied your request. The Plan says coverage for this device is limited to four months. An additional four months cannot be covered.The Plan must follow Medicare rules. Medicare rules say that a Negative Pressure Wound Therapy device cannot be covered for greater than four months. We looked at the file and Medicare rules. The record shows the device has already been in use for four months. Based on this information, we decided that Medicare rules for coverage of the wound vac have not been met.Therefore, we decided that the Plan does not have to pre-approvea Negative Pressure Wound Therapy Device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve power wheelchair (PWC) repairs. 
 
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 covered. 
 
The Plan must follow Medicare rules. The rules say that DME repairs are covered after the reasonable lifetime 
period has expired or in the case of irreparable damage. 
 
We looked at the file and Medicare rules. The services at issue are PWC repairs. The file shows that the PWC 
was not obtained through the Plan. There is no documentation that the PWC repairs meet the Medicare criteria 
for coverage. 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 power wheelchair (PWC) repairs.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve durable medical equipment to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve durable medical equipment. You say that you would like approval for these 
services. The Plan denied your request. The Plan says there are in-network providers available for these 
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 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 
durable medical equipment to be provided by an out of network (OON) provider.