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

We decided that the Plan does not have to pre-approve a walker folding wheeled (E0143) and walker seat
attachment (E0153).
You asked the Plan to pre-approve a walker and seat attachment. You say that the items are medically
necessary. The Plan denied your request. The Plan says the information received indicates that you have the
same or similar durable medical equipment, in good condition, less than 5 years old for the same medical need.
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered
reasonable and necessary.
The file shows that the enrollee has a standard wheelchair (K0001). A standard wheelchair (K0001) serves the
same purpose as a walker and seat attachment. Therefore, we decided that the Plan does not have to pre-
approve a walker folding wheeled (E0143) and walker seat attachment (E0153).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xgeva.

You asked the Plan to pre-approve Xgeva. The Plan denied your request. The Plan says the enrollee has not met the step therapy criteria.

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 Xgeva. Our reviewer says that Xgeva is not medically reasonable and necessary in this case. Our physician reviewer found that the record indicates that the enrollee has multiple myeloma, in remission. The requested medication is a new start. The provided records do not indicate that the enrollee has tried and failed the Plan's preferred step one alternative. The record does not indicate that the enrollee has a contraindication to or would have an adverse effect from the Plan's preferred step one alternative. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Xgeva have not been met. Therefore, we decided that the Plan does not have to pre-approve Xgeva.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (D2750) tooth #18 to be provided by a
participating provider.
You asked the Plan to pre-approve a crown. You say that you would like the Plan to approve and pay for this
crown. The Plan denied your request. The Plan says the benefit limit for D2750 has already been exhausted.
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 one crown per
tooth every 60 months.
We looked at the file and Medicare rules. Evidence was provided to show that a crown was provided for tooth
#18 on October 13, 2020. Based on this information, we decided that the Plan's rules for coverage of a crown
has already been exhausted. Therefore, we decided that the Plan does not have to pre-approve a crown (D2750)
tooth #18 to be provided by a participating provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says the enrollee's needs
can be met at a lower level of care.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.
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 IRF care. Our physician reviewer found
that the enrollee is at moderate assist for sitting up, maximal assist for standing, total assist for bed to chair
transfers. The enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee
is not shown to require, or to be able to tolerate, fifteen hours per week of rehabilitative services and regular
physician evaluation.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Koya Dayspring Device (non-pneumatic compression
controller with garment).
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 records show that you have
lymphedema due to breast cancer in your right arm. You have been undergoing therapy for the lymphedema.
There is insufficient evidence in the medical literature to support that the requested device is as effective as a
pneumatic sequential compression device. Additionally, the device has Bluetooth technology and a companion
application that exceeds your medical need. The services are therefore 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-approve a Koya Dayspring Device (non-pneumatic compression controller with garment).
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve SNF care.
You asked the Plan to pre-approve SNF care. The Plan denied your request. The Plan says that the request is
not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the
enrollee does qualify for SNF coverage. Our physician reviewer found that the member is reportedly
functioning below her baseline and has yet to reach a plateau in function. A period of daily skilled therapy is
reasonable to improve the enrollee's strength, train caregivers, establish a maintenance program and/or prevent
deterioration of the enrollee'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 SNF care have been met. The Plan must continue coverage for the SNF skilled
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve SNF care.
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: Unfavorable

We decided that the Plan does not have to pre-approve a leadless pacemaker (33274).

You asked the Plan to pre-approve a leadless pacemaker (33274). You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the enrollee 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 looked at the file and Medicare rules. In this case, Medicare guidelines say leadless pacemakers are non-covered when furnished outside of a CMS approved CED study. The file does not show that the enrollee is to have the procedure performed under a CMS approved CED study. Based on this information, we decided that Medicare rules for coverage of a leadless pacemaker (33274) have not been met. Therefore, we decided that the Plan does not have to pre-approve a leadless pacemaker (33274).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Magnetic resonance imaging (MRI) of the shoulder.
You asked the Plan to pre-approve an MRI of the shoulder. You say that the requested MRI of the shoulder is
medically necessary. The Plan denied your request. The Plan says the requested MRI of the shoulder is not
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 an MRI of the shoulder. Our reviewer
says that the requested MRI of the shoulder is not medically necessary. Our physician reviewer found detailed
documentation is not evident regarding trial and failure of recent, reasonable, and comprehensive less invasive
conservative care measures. Advanced imaging, such as MRI, is not typically indicated for acute shoulder pain
when red flags are not present and there has not been a well-documented, recent failure of conservative care
measures. This is not fully evident in this clinical scenario. There is no compelling rationale presented or
extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines.
Therefore, the request for the MRI of the shoulder is 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 an MRI of the shoulder have not been met. Therefore, we decided that the Plan
does not have to pre-approve a Magnetic resonance imaging (MRI) of the shoulder.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve personal care services, per 15 minutes (T1019).
You asked the Plan to pre-approve personal care services. You say that the enrollee has had a home helper in the past. You also say that a home helper is necessary due to ongoing medical conditions. The Plan denied your request. The Plan says
The Plan must follow Medicare rules. Medicare rules say that procedure code T1019 - personal care services, per 15 minutes - has a Status Code of "I", indicating that this code is not valid for Medicare purposes and is not payable. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of personal care services have not been met. Specifically, the file shows that procedure code T1019 - personal care services, per 15 minutes - has a Status Code of "I", indicating that this code is not valid for Medicare purposes and is not payable. Therefore, we decided that the Plan does not have to pre-approve personal care services, per 15 minutes (T1019).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crutch substitute (E0118).
You asked the Plan to pre-approve a crutch substitute. You say that the item is medically necessary. The Plan
denied your request. The Plan says the item is not medically necessary.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the knee scooter have not been met. Specifically, this item is not a covered benefit of Medicare or
the Plan. Therefore, we decided that the Plan does not have to pre-approve a crutch substitute (E0118).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) supplies rendered on
May 20, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says there is no valid standard written order.
The Plan must follow Medicare rules. Medicare rules say that a standard written order (SWO) is required for all
durable medical equipment (DME) and supplies.
We looked at the file and Medicare rules. The file shows that there is no valid SWO supporting the billed
supplies. Therefore, we decided that the Plan does not have to pay for the continuous glucose monitor (CGM)
supplies rendered on May 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide additional payment for the unspecified preventive procedure,
by report (D1999), periodontal scaling and root planing - four or more teeth per quadrant (D4341), and drugs or
medicaments dispensed in the office for home use (D9630) provided July 1, 2021.
You asked the Plan to provide additional payment for the unspecified preventative procedure, periodontal
scaling and root planing and drugs dispensed for home use. You say that the cost is too high. The Plan denied
your request. The Plan says you have used your full dental allowance and no further reimbursement is due.
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
unspecified preventative procedure, periodontal scaling and root planing and drugs dispensed for home use up
to the $1,000 dental allowance amount.
We looked at the file and Medicare rules. At the time the claims were processed you had $457 remaining in
your dental allowance. This remaining amount was applied to the dental services provided July 1, 2021.
Therefore, we decided that the Plan does not have to provide additional payment for the unspecified preventive
procedure, by report (D1999), periodontal scaling and root planing - four or more teeth per quadrant (D4341),
and drugs or medicaments dispensed in the office for home use (D9630) provided July 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bitewings - four radiographic images (D0274) provided October 5, 2021.

You asked the Plan to pay for the bitewing x-rays. You say that this is the first time you have used the Plan for this dentist. The Plan denied your request. The Plan says you have exceeded the frequency limit for this service.

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 bitewing x-rays once per plan year. 

We looked at the file and Medicare rules. The Plan provided documentation showing that bitewing x-rays were previously covered on March 24, 2021. Based on this information, we decided that the Plan's frequency limit
for coverage of the bitewing x-rays has been exceeded. Therefore, we decided that the Plan does not have to pay for the bitewings - four radiographic images (D0274) provided October 5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the spinal cord stimulator.
You asked the Plan to pre-approve the spinal cord stimulator. You say that you would like reconsideration because the spinal cord stimulator is medically necessary. The Plan denied your request. The Plan says the member does not meet Medicare criteria for coverage of the spinal cord stimulator.
The Plan follows Medicare rules. Medicare rules say that spinal cord stimulators may be covered as therapy for relief of chronic intractable pain, provided that the implantation of the stimulator is used only as a late resort (if not a last resort) for patients with chronic intractable pain.
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 spinal cord stimulator. Our reviewer says that there is no documentation of a surgical consult for neck pain. Our physician reviewer found all treatment modalities have not been tried. 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 spinal cord stimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve the spinal cord stimulator.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an intraosseous ablation procedure.
You asked the Plan to pre-approve the requested services. You say that the enrollee's pain is disabling. The Plan denied your request. The Plan says the clinical effectiveness in the setting of chronic low back pain has not been demonstrated.
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 requested services. Our physician reviewer found that the enrollee has chronic low back pain. She has tried Mobic, Ibuprofen and Tylenol and also has had an epidural steroid injection without sustained relief. An MRI shows Modic Type II changes at L3-L4. The request is for radiofrequency ablation of the Basivertebral nerves. This is an experimental and investigational procedure. Therefore, the request is considered 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 the requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve an intraosseous ablation procedure.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that you need to be transferred to an LTACH. The Plan denied your request. The Plan says the criteria for admission to an LTACH are not met. Your medical needs are being met in the current acute setting. The LTACH would add no additional services. With more time in the current setting, clinical stability can be ensured such that the appropriate lower level of care can be determined.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 

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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found you appear to be more stable and are improving but do not require more than short-term additional acute care services including additional weaning attempts that can be safely administered at the current facility. You do not require services at the LTACH that are not already available and covered at the current facility. Transfer to the LTACH is not medically necessary as it would not be clinically advantageous. Transfer to a lower level of care may be considered when treatment has completed.

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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the hereditary assessment for cardiac conditions provided on
September 7, 2021.
You asked the Plan to pay for the hereditary assessment for cardiac conditions. You say that you would like the
plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a
covered benefit.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed in the Medicare rules section, are not covered. Cardiovascular risk assessment panels are only
covered for certain indications.
While cardiovascular risk assessment panels are covered for certain indications, the file does not support that
the enrollee met criteria for these services. Therefore, we decided that the Plan does not have to pay for the
hereditary assessment for cardiac conditions provided on September 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two core buildups, including any pins when required
(D2950 x2), gingival irrigation (D4921), two pontic (D6245 x2), three retainer crowns (D6740 x3), bone
replacement graft for ridge preservation (D7953), and surgical extraction (D7210) provided on September 30,
2021, by an OON provider.
You asked the Plan to pay for the core buildups, gingival irrigation, pontic, retainer crowns, bone replacement
graft, and surgical extraction. You say that these services were rendered due to an emergency. You also say that
you are on a fixed income and the amount is too much for you. The Plan denied your request. The Plan says the
core buildups, gingival irrigation, pontic, retainer crowns, and bone replacement graft are not covered expenses
under your dental plan. The Plan also says that services performed by an OON provider are not covered
because your healthcare plan does not have OON benefits.
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. You are also responsible for 100% of the cost for dental services
rendered by an OON provider. Therefore, we decided that the Plan does not have to pay for the two core
buildups, including any pins when required (D2950 x2), gingival irrigation (D4921), two pontic (D6245 x2),
three retainer crowns (D6740 x3), bone replacement graft for ridge preservation (D7953), and surgical
extraction (D7210) provided on September 30, 2021, by an OON provider.