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

 We decided that the Plan does not have to pre-approve a power seat elevation system.  You asked the Plan to pre-approve a power seat elevation system. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested item is not medically necessary.  The Plan must follow Medicare rules. Medicare rules say that a power seat elevation system is non-covered.  We looked at the file and Medicare rules. The requested item is specifically not covered. Based on this information, we decided that Medicare rules for coverage of a power seat elevation system have not been met. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation system.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the home health services.

You asked the Plan to pre-approve the home health services.. You say that you would like reconsideration because the requested home health services are medically necessary. The Plan denied your request. The Plan says the member does not meet Medicare coverage criteria for the requested services.

The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 

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 home health services.. Our reviewer says that the requested home health services are not medically reasonable and necessary. Our physician reviewer found the enrollee does not have documented, ongoing, skilled nursing needs or documented skilled therapy needs. The enrollee is functioning at a level commiserate with a lower level of 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 the home health services. have not been met. Therefore, we decided that the Plan does not have to pre-approve the home health services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve incontinence supplies (diapers).  You asked the Plan to pre-approve incontinence supplies. You say that the enrollee needs diapers. The Plan denied your request. The Plan says the requested supplies 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 (diapers).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a wig.

You asked the Plan to pre-approve a wig. You say that you have cancer and this wig is no more cosmetic than the breast prosthesis. The Plan denied your request. The Plan says the requested item is not a covered benefit.

Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are ordered by a physician. The Plan follows these same rules. 

In this case, although the wig may be appropriate, it does not meet the definition of the above benefit categories. It is not considered DME because it does not directly treat a medical condition. It does not meet the Medicare definition of a prosthetic because it does not replace an internal body organ or attached tissue. As such, it is noncovered by Medicare. Furthermore, the Plan does not offer a supplemental benefit which would provide coverage for a wig. Therefore, we decided that the Plan does not have to pre-approve a wig.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve core buildups, including any pins when required (D2950) for tooth #'s 5 and 12.  You asked the Plan to pre-approve the core buildups. The Plan denied your request. The Plan says this service is not covered under the enrollee's benefit 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 pre-approve core buildups, including any pins when required (D2950) for tooth #'s 5 and 12.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve twenty (20) additional ST visits.

You asked the Plan to pre-approve additional ST visits. You say that additional speech therapy is medically necessary. The Plan denied your request. The Plan says twenty (20) additional speech therapy visits are not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 

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 twenty (20 additional ST visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found that based on the limited available records, the enrollee does not meet Medicare coverage criteria for the requested additional speech therapy visits beyond the number approved. There is no documentation of the reason for the cognitive decline. The documentation does not support coverage for additional therapy visits which are not medically necessary. The requested therapy is not generally accepted as specific and effective therapy for the enrollee's condition. There is no documentation of the etiology or prognosis of the cognitive decline. The records do not demonstrate that the unique skills of a professional therapist are required to provide treatment safely and effectively, that the services can be safely and effectively performed only by a therapist, or for physical therapy and occupational therapy, by or under the supervision of a therapist. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of twenty 20 additional ST visits have not been met. Therefore, we decided that the Plan does not have to pre-approve twenty (20) additional ST visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Budesonide.

You asked the Plan to pre-approve Budesonide. You say that you would like reconsideration because this drug is medically necessary. The Plan denied your request. The Plan says this drug is self-administered and not covered under Medicare Part B.

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 pre-approve Budesonide.

Benefits for Budesonide 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a very heavy duty group 2 power operated scooter (K0808).

You asked the Plan to pre-approve the scooter. You say that you are unable to see your health care provider, and continues to miss appointments due to not having a scooter. The Plan denied your request. The Plan says based on your weight, a heavy duty power scooter would be indicated, rather than a very heavy duty power scooter.

The Plan must follow Medicare rules. Medicare rules say that if K0808 is provided, it will be denied as not reasonable and necessary. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home.

The requested scooter is statutorily not covered by Medicare, as it has features that are meant for use outside of the home. Durable medical equipment cannot be covered for use outside of the home. Additionally, the requested scooter is intended for patients with a weight between 451 and 600 pounds. You weigh less than this weight range. Based on this information, we decided that Medicare rules for coverage of the scooter have not been met. Therefore, we decided that the Plan does not have to pre-approve a very heavy duty group 2 power operated scooter (K0808).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor for the enrollee.

You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your request. The Plan says the requested monitor is not covered you are not on insulin.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and 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 assesses 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 monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve additional PT visits.  You asked the Plan to pre-approve additional PT visits. The Plan denied your request. The Plan says additional PT is not medically necessary.  The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.  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 additional PT visits.  Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found that based on review of the limited available records, the enrollee does not meet Medicare coverage criteria for the requested additional physical therapy visits. She has not demonstrated any significant progress with the multiple physical therapy sessions in that she is only a few degrees of goal achievement for knee flexion (3 degrees) hip extension (2 degrees). It is not indicated to continue therapies when the progress is so slow, and the range of motion (ROM) can be maintained or increased with a home exercise program (HEP). Also, the goals may be unrealistic after receiving home health physical therapy (PT) and skilled nursing facility PT and in the outpatient setting a year after the surgeries. The documentation does not support coverage for additional therapy visits which are not medically necessary just to improve her ROM or strength. Much of what the PT is doing during therapy can be done by the enrollee with HEP given to her. The requested therapy is not generally accepted as specific and effective therapy for the enrollee's condition. The records do not demonstrate that the unique skills of a professional therapist are required to provide treatment safely and effectively, that the services can be safely and effectively performed only by a therapist, or for physical therapy and occupational therapy, by or under the supervision of a therapist. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of additional PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve additional PT visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Optichamber Diamond.

You asked the Plan to pre-approve the item. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered benefit.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The requested item is a mechanism for self-administering drugs. Therefore, we decided that the Plan does not have to pre-approve the Optichamber Diamond.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a maxillary partial denture (D5213).  You asked the Plan to pre-approve the maxillary partial denture. The Plan denied your request. The Plan says this service is not covered under the enrollee's 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 pre-approve a maxillary partial denture (D5213).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ten (10) additional ST visits.

You asked the Plan to pre-approve ten (10) additional ST visits. You say that additional speech therapy visits are medically necessary. The Plan denied your request. The Plan says additional speech therapy visits are not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.

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 ten (10) additional ST visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found that based on the review of the limited available records, the enrollee does not meet Medicare coverage criteria for the requested 10 additional speech therapy visits beyond the number approved. There are no clinical details of the extent of the stroke and the initial deficits after the stroke to support the medical necessity for the speech therapy sessions. The documentation does not support coverage for additional therapy visits, which are not medically necessary. The requested therapy is not generally accepted as specific and effective therapy for the enrollee's condition. The records do not demonstrate that the unique skills of a professional therapist are required to provide treatment safely and effectively, that the services can be safely and effectively performed only by a therapist, or for physical therapy and occupational therapy, by or under the supervision of a therapist. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of ten (10) additional ST visits have not been met. Therefore, we decided that the Plan does not have to pre-approve ten (10) additional ST visits.
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 you would like reconsideration because the requested IRF services are medically necessary. The Plan denied your request. The Plan says you do not meet Medicare criteria for coverage of the requested IRF care.  The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found you do not require the intensity of services provided at an IRF.   Specifically, you are not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation.  Your care needs can be met at a lower level of 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve non-sterile gloves.

You asked the Plan to pre-approve the gloves. You say that these are needed for two wounds that also have to be dressed. The Plan denied your request. The Plan says this is not a covered benefit.

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 non-sterile gloves.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a walk-in bathtub.  You asked the Plan to pre-approve a walk-in bathtub. You say that this is medically necessary. The Plan denied your request. The Plan says this is not covered.  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 a walk-in bathtub.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an out-of-network referral for hand surgery.

You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says the request can be administered by in-network providers.

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 services. Therefore, we decided that the Plan does not have to pre-approve an out-of-network referral for hand surgery.
Appeal type: Step-Therapy
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Ziextenzo for the enrollee.  You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says this is not medically necessary.  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 the drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found the plan requires a trial of Neulasta, Fulphila or Udenyca before they will approve the requested drug. In this case, the enrollee has not tried and failed the required drugs. There is no documentation indicating that these drugs would likely be less effective and/or likely to 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 the drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Ziextenzo for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.

You asked the Plan to pre-approve foot orthotics. You say that you have plantar fasciitis a well recognized medical condition that causes pain and reduces the ability to purse healthy physical activity. The Plan denied your request. The Plan says this item is not a covered benefit.

Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. 

Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Lantus Solostar injection 100/MI for the enrollee.  You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says this request is on the self-administered drug list.  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 pre-approve Lantus Solostar injection 100/MI for the enrollee.