Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (D2752) and core build up (D2950) for tooth # 32.
You asked the Plan to pre-approve the dental services. You say that these services will restore the integrity of the enrollee's tooth structure. You also say that it will provide a good long term prognosis. The Plan denied your request. The Plan says the services are not medically necessary.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the dental services when the services are medically necessary and reasonable. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the dental services. Our reviewer says that the crown and associated core build up for tooth # 32 are not medically necessary.
Our physician reviewer found the provided documentation indicates that tooth # 32 has existing restorations that are relatively shallow. The reviewer found that there are 3 surfaces and 1 cusp involved. This is less than what is considered necessary for a crown. Therefore, the reviewer found that the requested crown and associated core build up are not reasonable or necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental services have not been met. Specifically, the file does not show significant breakdown that would warrant a crown. Therefore, we decided that the Plan does not have to pre-approve a crown (D2752) and core build up (D2950) for tooth # 32.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex Superion Spacer.

You asked the Plan to pre-approve the Vertiflex Superion Spacer. You say that you would like reconsideration because the requested procedure is medically necessary. The Plan denied your request. The Plan says the requested procedure is considered experimental.

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 Vertiflex Superion Spacer. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is considered experimental as two learned Orthopedic societies have not endorsed it. Additionally, the member has a contra-indication to this 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 the Vertiflex Superion Spacer have not been met.

Therefore, we decided that the Plan does not have to pre-approve the Vertiflex Superion Spacer.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex Superion spacer.

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 enrollee has chronic low back pain and lumbar spinal stenosis with neurogenic claudication. The Food and Drug Administration (FDA) states that the Superion spacer is contraindicated for individuals with a body mass index (BMI) of greater than 40. The enrollee has a BMI of 43; therefore, the services are not 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 Vertiflex Superion spacer.
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. You say that this is medically necessary. The Plan denied your request. The Plan says it is not reasonable to expect the enrollee would be able to take part in 3 hours of therapy a day.

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 reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for surgical management of a hip fracture and for a urinary tract infection. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.

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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two connecting bars, implant overlay with 2 implants,
implant overlay with 4 implants, and two denture metal reinforcements to be rendered by an out-of-network
(OON) provider.
You asked the Plan to pre-approve two connecting bars, implant overlay with 2 implants, implant overlay with
4 implants, and two denture metal reinforcements.. You say that you have been told that the Plan should have
to continue to allow coverage with the requested OON provider. The Plan denied your request. The Plan says
coverage would require that you seek care from a dentist belonging to the Plan's dental network providers.
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
covered when they are received by anyone other than your assigned Plan dentist. Therefore, we decided that the
Plan does not have to pre-approve two connecting bars, implant overlay with 2 implants, implant overlay with
4 implants, and two denture metal reinforcements to be rendered by an out-of-network (OON) provider.
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 upper denture was misplaced, and you believe it was thrown away. You also say that if you remain without dentures you will be unable to eat. 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 September 17, 2018 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided on October 16, 2020.
You asked the Plan to pay for the self-administered drugs. You say that the enrollee's insurance should have paid this bill due to her inability to tolerate dental care in the dentist's office. The Plan denied your request. The Plan says self-administered drugs are not covered by Medicare or the enrollee's health plan.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs provided on October 16, 2020.
Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a maxillary partial denture (D5213) and a mandibular partial denture (D5214).

You asked the Plan to pre-approve the maxillary partial denture and mandibular partial denture. You say that the enrollee has broken their original upper partial, and they need it to properly chew and digest food. You also say that the enrollee is suffering from a financial hardship and is unable to pay for this necessary treatment without assistance. The Plan denied your request. The Plan says these services exceed the maximum counts 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, maxillary partial denture (D5213) and mandibular partial denture (D5214) are each limited to one procedure every five plan years.

The record shows that the enrollee received a maxillary partial denture (D5213) and mandibular partial denture (D5214) on April 7, 2021 and the enrollee's maxillary partial denture (D5213) and mandibular partial denture (D5214) benefits have been exhausted. Therefore, we decided that the Plan does not have to pre-approve a maxillary partial denture (D5213) and a mandibular partial denture (D5214).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the lumbosacral radiofrequency ablation (RFA).

You asked the Plan to pre-approve the RFA. You say that you would like reconsideration because the requested
procedure is medically necessary. The Plan denied your request. The Plan says the member does not meet
Medicare criteria for coverage of the RFA procedure.

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 RFA. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found Radiofrequency ablation for denervation, whether performed using traditional, cooled, or
pulsed radiofrequency, is considered investigational and therefore, not 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 RFA have not been met. Therefore, we decided that the Plan does not have to pre-approve the lumbosacral radiofrequency ablation (RFA).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the gastrointestinal (GI) tract capsule endoscopy.
You asked the Plan to pre-approve the GI tract capsule endoscopy. You say that you would like reconsideration
because the requested service is medically necessary. The Plan denied your request. The Plan says the member
does not meet Medicare criteria for coverage of the requested endoscopy.
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 GI tract capsule endoscopy. Our
reviewer says that the requested items/services are not considered medically reasonable and necessary in this
case. Our physician reviewer found the LCD requires upper and lower GI endoscopies within the past 12
months (esophagogastroduodenoscopy (EGD) and colonoscopy that have failed to identify a bleeding source.
The member's last colonoscopy was performed 23 months ago.
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 GI tract capsule endoscopy have not been met. Therefore, we decided that
the Plan does not have to pre-approve the gastrointestinal (GI) tract capsule endoscopy.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an epidural steroid injection.
You asked the Plan to pre-approve an epidural steroid injection. You say that the requested epidural steroid injection is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested epidural steroid injection.
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 epidural steroid injection. Our reviewer says that the enrollee does not meet criteria for the requested epidural steroid injection. Our physician reviewer found according to the coverage criteria, an epidural steroid injection (ESI) is indicated for the treatment of pain: Pain duration of at least four (4) weeks, and the inability to tolerate non-invasive conservative care or medical documentation of failure to respond to four (4) weeks of non-invasive conservative care, or acute herpes zoster refractory to conservative management where four (4) week wait is not required. In this case, the pain has been present for 2 weeks. The review has determined that the enrollee does not meet the above LCD coverage criteria for the requested epidural steroid injection. 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 epidural steroid injection have not been met. Therefore, we decided that the Plan does not have to pre-approve an epidural steroid injection.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuation of skilled nursing facility (SNF) services.

You asked the Plan to pre-approve continued SNF services. The Plan denied your request. The Plan says that your request does not meet Medicare guidelines because there are no noted daily skilled complex nursing or therapy needs which would meet the guidelines for continued SNF services.

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 continued SNF services. Our reviewer says that you do not meet the Medicare criteria for SNF care. Our physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. Our reviewer found that you do not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. Our physician reviewer also found that you do not require daily skilled nursing and/or skilled therapy on an inpatient 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 continued SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuation of skilled nursing facility (SNF) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Osteogenesis stimulator.

You asked the Plan to pre-approve the Osteogenesis stimulator. You say that you would like reconsideration because the requested stimulator is medically necessary. The Plan denied your request. The Plan says the member does not meet Medicare criteria for coverage of the requested stimulator.

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 Osteogenesis stimulator. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the member had charcot ankle reconstruction surgery. Not enough time has passed since the surgery to clearly establish failure of bone fusion after surgery. More followup is needed. 

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 Osteogenesis stimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve the Osteogenesis stimulator.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve BRCA genetic 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 services are not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that BRCA testing 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 not medically necessary. Our physician reviewer found the enrollee has a history of right breast cancer that is estrogen receptor positive and now has metastatic disease. The records do not support that the criteria for coverage of BRCA testing are met. The services are 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 BRCA genetic testing.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the pontic (D6240) and two retainer crowns (D6750 x2) provided on October 4, 2021.
You asked the Plan to pay for the pontic and retainer crowns. You say that the dental office did not submit a treatment plan. You also say that you would have never started the program. The Plan denied your request. The Plan says these dental services are not covered by this Medical Plan.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the pontic (D6240) and two retainer crowns (D6750 x2) provided on October 4, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a mastopexy procedure.

You asked the Plan to pre-approve a mastopexy. The Plan denied your request. The Plan says this 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 mastopexy. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the record indicates that the enrollee had a previous breast implant removed due to the performance of a thoracic clamshell incision for bilateral lung transplantation. The record indicates that she has grade II ptosis and no documentation of intertrigo or other accepted indications for the requested procedure. The record indicates that the requested procedure is being performed for cosmetic reasons. The record provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested service.

 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 mastopexy have not been met.

Therefore, we decided that the Plan does not have to pre-approve a mastopexy procedure.