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

We decided that the Plan does not have to pre-approve an electronic connection (E2311).

You asked the Plan to pre-approve an electronic connection (E2311). You say that the requested electro connect (E2311) is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested electro connect (E2311).

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 an electronic connection (E2311). Our reviewer says that the enrollee does not meet criteria for the requested electro connect (E2311). Our physician reviewer found the electro connect (E2311) is not medically necessary per Local Coverage Article: Wheelchair Options/Accessories - Policy Article (A52504). The enrollee does not require non-proportional input devices (e.g., sip and puff, head array, etc.). The enrollee does not require a separate display (i.e., for alternate control devices), other electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive control), or an attendant control. The enrollee does not need to control the power options through a joystick. The enrollee's upper extremity strength and function support that the enrollee can control any power options through their own switches.

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 electronic connection (E2311) have not been met. Therefore, we decided that the Plan does not have to pre-approve an electronic connection (E2311).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia.
You asked the Plan to pre-approve Prolia. You say that the enrollee cannot take bisphosphonates. The Plan denied your request. The Plan says step therapy requirements have not been met.
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 Prolia. Our reviewer says that the requirements for coverage of Prolia have not been met. Our physician reviewer found the Plan requires a trial of an oral bisphosphonate drug and zoledronic acid (generic Reclast) before they will approve the requested drug. In this case, the patient has not tried and failed the required drugs. There is no documentation provided indicating that the plan's required drugs would likely be less effective or have adverse effects for the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dexamethasone sodium phosphate (J1100), paclitaxel(J9267), pembrolizumab(J9271) and carboplatin (J9045).
You asked the Plan to pre-approve dexamethasone sodium phosphate, paclitaxel, pembrolizumab and carboplatin. You say that you would like reconsideration because the requested drug regimen is medically necessary. The Plan denied your request. The Plan says the requested regimen is 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 dexamethasone sodium phosphate, paclitaxel, pembrolizumab and carboplatin. Our reviewer says that FDA approval is for first-line treatment (in combination with pemetrexed and platinum chemotherapy) of metastatic nonsquamous non-small cell lung cancer in patients with no estimated glomerular filtration rate (EGFR) or ALK genomic tumor aberrations. this regimen is for squamous cell and this patient has no testing for EGFR documented. Our physician reviewer found other regimens are better tolerated and considered first line. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of dexamethasone sodium phosphate, paclitaxel, pembrolizumab and carboplatin have not been met. Therefore, we decided that the Plan does not have to pre-approve dexamethasone sodium phosphate (J1100), paclitaxel(J9267), pembrolizumab(J9271) and carboplatin (J9045).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Intracept procedure.
You asked the Plan to pre-approve the Intracept procedure. You say that the requested Intracept procedure is medically necessary. The Plan denied your request. The Plan says the requested Intracept procedure is 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 the Intracept procedure. Our reviewer says that the requested Intracept procedure is not medically necessary. Our physician reviewer found the Intracept procedure is an experimental/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 Intracept procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the Intracept procedure.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve computed tomography (CT) of abdomen and pelvis (74176).
You asked the Plan to pre-approve the diagnostic. You say that the requested service is medically necessary and you would like to appeal the denial. The Plan denied your request. The Plan says that the records do not support that the requested CT scan of the abdomen and Pelvis is medically necessary.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the diagnostic. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found based on the criteria for CT, the enrollee meets the criteria. The enrollee has dyspnea on exertion and weight loss and chest x-ray results showed a new mass on right lung warranting CT follow-up. Therefore, this request for the CT of the thorax will be considered medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the diagnostic have been met. Therefore, we decided that the Plan has to pre-approve computed tomography (CT) of abdomen and pelvis (74176).
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 the Intracept procedure.
You asked the Plan to pre-approve the Intracept procedure. You say that the requested Intracept procedure is medically necessary. The Plan denied your request. The Plan says the requested Intracept procedure is 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 the Intracept procedure. Our reviewer says that the requested Intracept procedure is not medically necessary. Our physician reviewer found the Intracept procedure is considered experimental/investigational. Therefore, the request is deemed not medically reasonable or necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Intracept procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the Intracept procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve shoe inserts (L3000).
You asked the Plan to pre-approve shoe inserts. You say that this was approved in the past. The Plan denied your request. The Plan says the requirements for coverage have not been met.
The Plan must follow Medicare rules. Medicare rules say that inserts and other shoe modifications (L3000) are covered if they are on a shoe that is an integral part of a covered brace and if they are medically necessary for the proper functioning of the brace. We looked at the file and Medicare rules. Although the records show that you have a covered brace, the records do not show that you have a shoe that is a part of the brace. Based on this information, we decided that Medicare rules for coverage of shoe inserts have not been met. Therefore, we decided that the Plan does not have to pre-approve shoe inserts (L3000).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6530.
You asked the Plan to pre-approve the compression stockings. You say that the enrollee is required to wear support stockings daily. The Plan denied your request. The Plan says this is not a covered service.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are noncovered because they do not meet the statutory definition of a surgical dressing. Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6530
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve alveoloplasty not in conjunction with extractions - one to three teeth or tooth spaces, per quadrant (D7321) and incisional biopsy of oral tissue-hard (bone, tooth) (D7285).

You asked the Plan to pre-approve alveoloplasty and incisional biopsy. You say that you would like the Plan to cover at least 50% of the cost of the services. The Plan denied your request. The Plan says these services are not covered under your 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. Therefore, we decided that the Plan does not have to pre-approve alveoloplasty not in conjunction with extractions - one to three teeth or tooth spaces, per quadrant (D7321) and incisional biopsy of oral tissue-hard (bone, tooth) (D7285).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve gastrointestinal tract imaging.

You asked the Plan to pre-approve gastrointestinal tract imaging. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.

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 gastrointestinal tract imaging. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found based on the medical records provided there is no documentation that the gastrointestinal tract imaging at issue in this case meets Medicare criteria for medically reasonable and necessary. Records do not document any history of undiagnosed blood loss anemia due to intestinal bleeding or suspected Crohn's disease. In addition, records report a history of intestinal blockage which is a contraindication to the procedure.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of gastrointestinal tract imaging have not been met. Therefore, we decided that the Plan does not have to pre-approve gastrointestinal tract imaging.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an interim partial denture (D5820).
You asked the Plan to pre-approve the dental item. You say that you do not have front teeth. You say that the teeth you do have will not support a full partial denture. You say that you really hate being without your front teeth. You also say that since you cannot wear a full partial, this should be covered. The Plan denied your request. The Plan says interim partial denture is not listed as a covered dental item.
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 an interim partial denture (D5820).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the manual wheelchair and accessories.
You asked the Plan to pre-approve the manual wheelchair and accessories. You say that the items are medically necessary. The Plan denied your request. The Plan says you reside in a skilled nursing facility (SNF).
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home. Records show that the manual wheelchair and accessories is being requested for use in a SNF or hospital. Therefore, we decided that the Plan does not have to pre-approve the manual wheelchair and accessories
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 requested items are a necessity for your care. The Plan denied your request. The Plan says the requested items are 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-approve a group three power wheelchair with special suspension.

You asked the Plan to pre-approve a group three power wheelchair with special suspension. You say that the services are 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 if a Group 3 PWC is provided and if criteria (IV)(A) - (IV)(D) are not met, it will be denied as not 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 a group three power wheelchair with special suspension. Our reviewer says that the services are not medically necessary. Our physician reviewer found while you may be able to safely operate a personal mobility device (PMD) the requested K0861 with multiple power options exceeds your medical need. The documentation does not reveal that your needs are at high risk for development of a pressure ulcer, or utilizes intermittent catheterization for bladder management, or needs a power seating system to manage increased tone or spasticity. The documentation does not support that it is medically necessary to control the requested power options through the joystick (drive interface). Your strength in the right extremity should be sufficient to control any power options through their own switches. The documentation does not reveal that tilt and recline are medically necessary therefore the request for Group 3 power wheelchair with multiple power options is not medically necessary per Local Coverage Determination (LCD): Wheelchair Options/Accessories (L33792) and Local Coverage Article: Wheelchair Options/Accessories - Policy Article (A52504).

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 group three power wheelchair with special suspension have not been met. Therefore, we decided that the Plan does not have to pre-approve a group three power wheelchair with special suspension.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Freestyle Libre Continuous Glucose Monitor (CGM).
You asked the Plan to pre-approve the Freestyle Libre CGM. You say that you would like reconsideration because the member is having trouble monitoring their blood glucose levels. The Plan denied your request. The Plan says the member does not meet Medicare coverage criteria for the requested 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.
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections or require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of the Freestyle Libre CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve the Freestyle Libre Continuous Glucose Monitor (CGM).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a mammogram to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve a mammogram. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services can be provided by a preferred provider.
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 a mammogram to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an extra battery for the portable oxygen concentrator (E1356).

You asked the Plan to pre-approve an extra battery for the portable oxygen concentrator. You say that the item is medically necessary. The Plan denied your request. The Plan says this item does not primarily serve a medical purpose.

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-approve an extra battery for the portable oxygen concentrator (E1356).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex device.
You asked the Plan to pre-approve a Vertiflex device. You say that the requested Vertiflex device is medically necessary. The Plan denied your request. The Plan says the requested Vertiflex device is 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 a Vertiflex device. Our reviewer says that the requested Vertiflex device is not medically necessary. Our physician reviewer found the Vertiflex device is considered an experimental/investigational procedure and will not address his extruded disc or his protruded disc. The request is deemed not medically reasonable or necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a Vertiflex device have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex device
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Cologuard testing.

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 criteria for coverage are not met.

The Plan must follow Medicare rules. Medicare rules say that Cologuard testing is covered for beneficiaries aged 50-85 years who meet specific criteria. 

We looked at the file and Medicare rules. The file shows that you are aged 48 years. 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 Cologuard testing.