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

We decided that the Plan does not have to pre-approve additional non-emergency transportation (A0100).
You asked the Plan to pre-approve the additional non-emergency transportation. You say that you fell and had a stroke and need additional rides. The Plan denied your request. The Plan says you have exhausted your transportation benefit for the 2021 plan year. The Plan also says that additional trips are not covered.
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 up to 10 one-way 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 additional non-emergency transportation (A0100).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve removal of torus mandibularis (D7473) and removal of torus palatinus (D7472).
You asked the Plan to pre-approve the dental services. You say that some of the services that were requested have been denied. You also say that you are going to have to pay over $700 out of pocket for the services. The Plan denied your request. The Plan says removal of torus mandibularis is not listed as a covered service. The Plan says that removal of torus palatinus is not listed as a covered service either.
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 services are not among
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve removal of torus mandibularis (D7473) and removal of torus palatinus (D7472).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve rimabotulinumtoxinB.

You asked the Plan to pre-approve rimabotulinumtoxinB. You say that the medication is necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

The Plan follows Medicare rules. Medicare rules say that botulinum toxins (Botox, Dysport, Xeomin and Myobloc), will be considered medically reasonable and necessary when administered for treatment of certain FDA-labeled indications and Off-label 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 rimabotulinumtoxinB. Our reviewer says that the medication is not medically necessary. Our physician reviewer found in this case, the record indicates that you have multiple sclerosis and low back spasms. The noted condition is not a condition enumerated in the coverage criteria. The elements of the coverage criteria are not satisfied. The requested service is not recommended. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of rimabotulinumtoxinB have not been met. Therefore, we decided that the Plan does not have to pre-approve rimabotulinumtoxinB.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that you need help recovering from hip surgery. The
Plan denied your request. The Plan says you do not require the skills of a licensed therapist or nurse.
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 services. Our physician reviewer
found that you are unsteady with your gait. You are walking 100 feet with a front wheeled walker with standby
assistance. You are at a supervision level for transfers and stand-by assist for activities of daily living. There is no documentation that you require skilled nursing or therapy services on a daily basis in a SNF setting.
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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve spinal decompression to be provided by a chiropractor.

You asked the Plan to pre-approve spinal decompression to be provided by a chiropractor. You say that spinal decompression will work for you as it is not as rough on your body as regular manipulation is. The Plan denied your request. The Plan says the requested services are not a covered benefit.

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. 

The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pre-approve spinal decompression to be provided by a chiropractor.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance transport provided on January 28, 2021.

You asked the Plan to pay for the ambulance transport. You say that this is a regular patient that you provide transportation services for and the services were medically necessary. You say that the services are not related to any hospice treatment and the claim should be reviewed for payment. The Plan denied your request. The Plan says Original Medicare is responsible for payment.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. 

The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the ambulance transport provided on January 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a retreatment of a previous root canal therapy (D3348).

You asked the Plan to pre-approve the retreatment of a previous root canal therapy. You say that your doctor
says that this procedure is medically necessary. The Plan denied your request. The Plan says this service is not
covered under your benefit package.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a
retreatment of a previous root canal therapy (D3348).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110).
You asked the Plan to pre-approve the complete maxillary denture. You say that your physician said it is medically necessary for you to have dentures due to your problems with your digestive system. The Plan denied your request. The Plan says this service 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 Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, complete maxillary denture (D5110) is limited to one procedure every five plan years. The record shows that you received a complete maxillary denture (D5110) on November 21, 2019 and your complete maxillary denture (D5110) benefit has been exhausted. Therefore, we decided that the Plan does not have to pre-approve a complete maxillary denture (D5110).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM).

You asked the Plan to pre-approve therapeutic CGM. You say that this device is helping your ability to modify and regulate drug use and behaviors instrumental in preventing long-term complications from diabetes. The Plan denied your request. The Plan says the denial of authorization for this device is correct, because you do not meet the Medicare criteria for a therapeutic CGM.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan. Medicare rules state that for Medicare to consider coverage for any item or service, the information submitted by the supplier/provider must corroborate the documentation in the medical record and confirm that coverage criteria have been met. 

We looked at the file and Medicare rules. Your treating physician did not submit any supporting medical records for this request. The Plan made several attempts to obtain medical records from your physician, but they were not submitted. Without medical records, it cannot be determined whether you meet the Medicare criteria for a therapeutic CGM. Therefore, the information submitted does not confirm that Medicare coverage criteria have been met. Based on this information, we decided that Medicare rules for coverage of therapeutic CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Freestyle Libre 14-day sensor kit.

You asked the Plan to pre-approve the Freestyle Libre 14-day sensor kit. You say that the item is medically necessary. The Plan denied your request. The Plan says you do not use insulin with at least three daily injections.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan. 

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of the Freestyle Libre 14-day sensor kit have not been met. Therefore, we decided that the Plan does not have to pre-approve the Freestyle Libre 14-day sensor kit.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a K3 foot.

You asked the Plan to pre-approve a K3 foot. You say that the item is medically necessary. The Plan denied your request. The Plan says there are no medical records from the physician to show that member is K3 ambulator.

The Plan must follow Medicare rules. Medicare rules say that overage is extended only if there is sufficient clinical documentation of functional need for the technologic or design feature of a given type of foot. This information must be retained in the treating practitioner's or prosthetist's files. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a K3 foot have not been met. Therefore, we decided that the Plan does not have to pre-approve a K3 foot.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a radiofrequency ablation procedure of the genicular nerves (64624).

You asked the Plan to pre-approve a radiofrequency ablation. You say that the requested procedure was previously performed with significant relief. The Plan denied your request. The Plan says rules for coverage have not been met because the requested procedure is experimental/investigational.

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 radiofrequency ablation. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the requested procedure is considered experimental/investigational. 

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 radiofrequency ablation have not been met. Therefore, we decided that the Plan does not have to pre-approve a radiofrequency ablation procedure of the genicular nerves (64624).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve outpatient mental health services to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve OON services. You say that you cannot find any other providers in the area who accept your insurance. The Plan denied your request. The Plan says there are in-network providers available.
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 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-approve outpatient mental health services to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the unspecified removable prosthodontic procedure
(D5899).

You asked the Plan to pre-approve the unspecified removable prosthodontic procedure (D5899). You say that
your sons' dog at the dentures. You say that you need to eat and have pain and swelling in your gums. The Plan
denied your request. The Plan says the denture was approved as a one-time exception and the unspecified
removable prosthodontic procedure remains denied as a non-covered benefit.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the
unspecified removable prosthodontic procedure (D5899).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill
(S9986).
You asked the Plan to pre-approve the special supplemental benefits for the chronically ill. The Plan denied
your request. The Plan says you do not meet the required criteria that makes you eligible for these benefits. The
Plan also says that you do not have a high risk of hospitalization or other adverse health outcomes, and do not
require intensive care coordination.
The Plan must follow Medicare rules. Medicare rules say that there is a special supplemental benefit for
enrollees with an eligible chronic condition.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the special supplemental benefits for the chronically ill have not been met. Specifically, we have
confirmed that you do not have one of the eligible conditions listed in the Evidence of Coverage. Therefore, we
decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill (S9986).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652).
You asked the Plan to pre-approve a pneumatic compression device. You say that the item is medically
necessary. The Plan denied your request. The Plan says the item is not medically necessary.
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 least four 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 pre-approve a pneumatic compression device
(E0652).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a mandibular partial denture (D5214).
You asked the Plan to pre-approve the mandibular partial denture. You say that your current denture does not
fit right. You also say that you cannot eat healthy foods such as fruits or vegetables. The Plan denied your
request. The Plan says this service 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 Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, mandibular partial denture (D5214) is
limited to one procedure every five plan years. The record shows that you received a mandibular partial denture
(D5214) on November 7, 2019, and your mandibular partial denture (D5214) benefit has been exhausted.
Therefore, we decided that the Plan does not have to pre-approve a mandibular partial denture (D5214).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional non-emergency transportation (A0100).
You asked the Plan to pre-approve the additional non-emergency transportation. You say that you have a lot of doctors' appointments and would like additional rides. The Plan denied your request. The Plan says you have utilized your benefit of 10 one-way trips for the 2021 plan 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 up to 10 one-way 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 additional non-emergency transportation (A0100).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve companion care (S5136) and home health aide services (S9122).

You asked the Plan to pre-approve companion care and home health aide services. You say that you are not able to live alone. The Plan denied your request. The Plan says these requested services are custodial and are not covered.

The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from trained medical or paramedical staff, is not covered. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of companion care and home health aide services have not been met. Specifically, we find that the services at issue in this case are considered custodial in nature. Therefore, we decided that the Plan does not have to pre-approve companion care (S5136) and home health aide services (S9122).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Fosaprepitant.
You asked the Plan to pre-approve Fosaprepitant. You say that this drug is medically reasonable and necessary. The Plan denied your request. The Plan says this drug is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 Fosaprepitant. Our reviewer says that the requested drug is not medically reasonable and necessary. Our physician reviewer found that the member has been diagnosed with metastatic non-small cell lung cancer. Fosaprepitant was requested to use as antiemetic prior to Gemcitabine. The review indicates that Gemcitabine falls under low emetic risk agent (10 percent - 30 percent frequency of emesis). Based on the National Comprehensive Cancer Network guidelines, Dexamethasone or Metoclopramide or Prochlorperazine or one of the 5HT3 receptor antagonists (Dolasetron, Granisetron, Ondansetron) is recommended. Fosaprepitant is a neurokinin 1 receptor antagonist and is not indicated for low emetic risk agents. The review has determined that the documentation does not support that Fosaprepitant is medically reasonable and necessary for the patient. The documentation does not support that Fosaprepitant is safe and effective for the patient. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Fosaprepitant have not been met. Therefore, we decided that the Plan does not have to pre-approve Fosaprepitant.