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

We decided that the Plan does not have to pre-approve a high frequency chest wall oscillation device
(HFCWOD) (Volara system).
You asked the Plan to pre-approve a HFCWOD. You say that this is medically necessary. The Plan denied your
request. The Plan says a review of the current medical literature indicates that this service is considered
experimental and investigational.
The Plan must follow Medicare rules. Medicare rules say the HFCWODs are covered only when they are
medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases.
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 HFCWOD. Our reviewer says that the
requested system is not medically reasonable or necessary. Our physician reviewer found based on the medical
records provided, there is no documentation that you have cystic fibrosis, bronchiectasis or one of the
neuromuscular diseases for which a high frequency chest wall oscillation device may be covered. There is no
documentation that the enrollee meets Medicare criteria for medically necessary for the requested Volara
system high frequency chest wall oscillation device.
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 HFCWOD have not been met. Therefore, we decided that the Plan does not
have to pre-approve a high frequency chest wall oscillation device (HFCWOD) (Volara system).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aid check and repair provided on June 14, 2021.
You asked the Plan to pay for the hearing aid check and repair. You say that your hearing aids were checked to see if they needed to be adjusted to your current hearing loss. You say that you thought the Plan covered such problems. The Plan denied your request. The Plan says these services are not covered.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. 
We looked at this physician's review, the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the hearing aid fitting and repair have not been met. Specifically, hearing aid repairs and related services are not a covered benefit. Therefore, we decided that the Plan does not have to pay for the hearing aid check and repair provided on June 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve endodontic therapy, molar tooth provided by a participating provider.
You asked the Plan to pre-approve endodontic therapy. You say that you would like approval for this dental work. The Plan denied your request. The Plan says the request dental service is not a covered 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. 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 endodontic therapy, molar tooth provided by a participating provider
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6549.
You asked the Plan to pre-approve the compression stockings. You say that you have peripheral edema in your legs, and it is getting worse. You are losing mobility and you are having problems getting in and out of your apartment. The Plan denied your request. The Plan says the requested item is not covered by Medicare or the Plan.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 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 A6549.
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 provided on an intermittent basis.
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 was admitted to the acute care hospital for weakness and hypotensive shock. His medical problems are stable. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program.
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 an initial 15 minutes of general anesthesia (D9222), an additional 15 minutes of general anesthesia (D9223 x 3), and therapeutic drug injection (D9612).
You asked the Plan to pre-approve the dental services. You say that the services should be covered. The Plan denied your request. The Plan says anesthesia is not a covered dental 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 dental anesthesia services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an initial 15 minutes of general anesthesia (D9222), an additional 15 minutes of general anesthesia (D9223 x 3), and therapeutic drug injection (D9612).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a bitewing x-ray (D0274) and a resin-based composite - one surface, posterior (D2391) provided by a participating provider on June 26, 2020, to September 28, 2020.
You asked the Plan to pay for a bitewing x-ray and a resin-based composite. You say that this has gone too far. You say that you do not agree with these charges. The Plan denied your request. The Plan says the benefit limit for the rendered services 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 a bitewing x-ray once per calendar year and two resin-based composites to be covered with a 50% coinsurance once per calendar year.
We looked at the file and Medicare rules. Evidence was provided to show that the benefit for D0274 was exhausted on August 26, 2021. Evidence was also provided to show that composite fillings were provided on September 8, 2021. Based on this information, we decided that the Plan's rules for coverage of a bitewing x-ray and a resin-based composite have already been met. Therefore, we decided that the Plan does not have to pay for a bitewing x-ray (D0274) and a resin-based composite - one surface, posterior (D2391) provided by a participating provider on June 26, 2020, to September 28, 2020.
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 does not have acute complex medical needs that require supervision by a rehabilitation physician.
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 was admitted to the acute care hospital for congestive heart failure and atrial fibrillation. He was discharged home with home health. His medical problems are stable. The complexity of his nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.
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: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gel-One.
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 step therapy requirement is not 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has knee osteoarthritis. He has not tried and failed the Plan's required drugs, Orthovisc and Monovisc. The records do not show that the required drugs would be contraindicated or less effective; therefore, Gel-One is 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 Gel-One.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric care from November 15, 2021, 
forward. 
 
You asked the Plan to pre-approve inpatient psychiatric care from November 15, 2021, forward. You say that 
the services at issue are medically necessary. The Plan denied your request. The Plan says the services at issue 
are not medically necessary. The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric care from 
November 15, 2021, forward. Our reviewer says that you do not meet the criteria for acute inpatient mental 
health treatment beyond the date in question of November 15, 2021, forward. Our physician reviewer found 
you did not require inpatient mental health treatment beyond November 15, 2021, as you were not a danger to 
yourself or others and did not have any delusions, auditory or visual hallucinations. It did not appear that active 
treatment was taking place beyond the date in question. It did not appear that the services for the dates in 
question were reasonably expected or medically necessary to improve your condition or for the purpose of 
diagnosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric care from November 15, 2021, forward have not been met. 
Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from November 15, 
2021, forward.
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 the enrollee has complex medical needs that require ongoing acute care. You say that the enrollee meets the LTACH admission criteria. The Plan denied your request. The Plan says the medical necessity of LTACH care has not been established. The Plan says that the enrollee's needs can be met at a lower level of care.
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 there is no documentation provided indicating medical necessity for admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he/she is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan.
The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a second pair of eyeglasses.
You asked the Plan to pre-approve a second pair of eyeglasses. You say that the optometrist made the eyeglasses wrong and as a result they hurt your head and you need a second pair of eyeglasses with a different material. The Plan denied your request. The Plan says you have already received a pair of eyeglasses this benefit year and you have exceeded your covered benefit.
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services every year.
We looked at the file and the Plan's rules. The file shows that you have exceeded the eyewear benefit. Therefore, we decided that the Plan does not have to pre-approve a second pair of eyeglasses.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve non-preferred brand test strips.
You asked the Plan to pre-approve a non-preferred brand. You say that the other test strips were not working. The Plan denied your request. The Plan says you do not meet the criteria for non-preferred items.
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 brand in this case is not a preferred brand with the Plan. The Plan has preferred brands available that can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these non-preferred services. Therefore, we decided that the Plan does not have to pre-approve non-preferred brand test strips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power tilt and recline system for a power wheelchair 
(PWC). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that if a wheelchair has an electrical connection device 
described by code E2310 or E2311 and if the sole function of the connection is for a power seat elevation or 
power standing feature, it will be denied as non-covered. We looked at the file and Medicare rules. The requested power tilt and recline system is described by code 
E2311 and not covered by Medicare. 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 power tilt 
and recline system for a power wheelchair (PWC).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a colonoscopy to be provided by an out-of-network provider.
You asked the Plan to pre-approve a colonoscopy to be provided by an out-of-network provider. The Plan denied your request. The Plan says out-of-network treatment is generally necessary when there are no in network physician assessable to provide the necessary services, or when obtaining in-network care would constitute a delay of care that would place the patient at a higher health risk. In this case there are available in-network providers for a colonoscopy.
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 a colonoscopy to be provided by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Coolief radiofrequency ablation (RFA) of the genicular nerve.
You asked the Plan to pre-approve genicular nerve RFA. You say that key clinical findings support the medical necessity of this procedure. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because genicular radiofrequency ablation 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 genicular nerve RFA. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this is considered to be an experimental/investigational procedure that is the subject of ongoing clinical trials.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of genicular nerve RFA have not been met. Therefore, we decided that the Plan does not have to pre-approve Coolief radiofrequency ablation (RFA) of the genicular nerve.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power mobility device (power wheelchair or scooter).
You asked the Plan to pre-approve a power mobility device. You say that the requested item is a necessity for your care. The Plan denied your request. The Plan says rules for coverage for the requested item have not been met.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. The file does not contain medical records that show you have a mobility deficit that impairs your participation in MRADLs. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a power mobility device (power wheelchair or scooter).
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve bioimpedance spectroscopy (BIS), extracellular fluid analysis for 
lymphedema assessment(s) (93702). 
 
You asked the Plan to pre-approve BIS services. You say that this procedure is medically necessary for the 
enrollee's condition. The Plan denied your request. The Plan says that the medical literature does not support 
that this measurement is the standard of care for the diagnosis of lymphedema nor that it has been shown to 
influence the treatment of lymphedema. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve BIS services. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee is a patient with a new diagnosis of breast cancer. Evidence suggests that 
monitoring with BIS allowing for early intervention significantly reduces the relative risk of chronic breast 
cancer treatment-related lymphedema (BCRL) with a 69% and 81% reduction compared to background and 
circumference, respectively. Circumference monitoring did not appear to provide a benefit with respect to 
chronic BCRL incidence. Based on these results, BIS should be considered for breast cancer treatment-related 
lymphedema BCRL screening in order to detect subclinical BCRL and reduce rates of chronic BCRL, 
particularly in high-risk patients. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of BIS services have been met. Therefore, we decided that the Plan has to pre-
approve bioimpedance spectroscopy (BIS), extracellular fluid analysis for lymphedema assessment(s) (93702).  
 
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.