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

 We decided that the Plan does not have to pre-approve the topical application of fluoride - excluding varnish (D1208), core buildup, including any pins when required (D2950), gingival irrigation - per quadrant (D4921), pontic - porcelain/ceramic (D6245), and retainer crown - porcelain/ceramic (D6740).  You asked the Plan to pre-approve the fluoride treatment, core buildup, gingival irrigation, pontics and retainer crowns. You say that these services are medically necessary for your delicate health condition. 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 the topical application of fluoride - excluding varnish (D1208), core buildup, including any pins when required (D2950), gingival irrigation - per quadrant (D4921), pontic - porcelain/ceramic (D6245), and retainer crown - porcelain/ceramic (D6740).
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a blepharoplasty of the upper eyelid (15823, 67904) to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve a blepharoplasty of the upper eyelid. You say that your vision is impaired, and you are not able to travel far due to the impaired vision. You also say you would like for this to be reconsidered and that there is a limited time to make this decision as this provider will be leaving the practice in January 2022. The Plan denied your request. The Plan says the requested service is available in-network, therefore, going out-of-network is not medically necessary at this time. The Plan also says that there are 41 in-network providers within a 20-mile radius of the member's zip code, and 3 of them do Oculoplastic Surgery.  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 blepharoplasty of the upper eyelid (15823, 67904) to be provided by an out-of-network (OON) provider.
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 IRF care is medically reasonable and necessary for your condition. The Plan denied your request. The Plan says rules for IRF care have not been met.  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 that you were admitted for anemia and gastrointestinal bleeding. Medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While you have a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. In conclusion, there is not a reasonable expectation that you 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: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Esterified Estrogen and Methyltestosterone.  You asked the Plan to pre-approve the requested drug. You say that the enrollee has tried weaning off hormone therapy without success. The Plan denied your request. The Plan says this drug is not eligible for coverage under the Part B benefit.  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 Esterified Estrogen and Methyltestosterone.   Benefits for the requested drug 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: 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 the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.  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 your current medical condition does not require intensive physician or nursing supervision in an IRF. You may benefit from additional physical and occupational therapy, but the documentation does not reveal that your functional level requires therapy on an intensive level 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: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a continuous glucose monitor.  You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your request. The Plan says there is no indication of three insulin treatments per day.  The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and necessary for enrollees with diabetes who meet the criteria referenced 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 the monitor. Our reviewer says that the requested monitor is not medically reasonable or necessary. Our physician reviewer found you are not taking three shots of insulin per day. You appear to be prescribed two shots per day. There is no reason given why a glucometer could not be used to satisfy your monitoring your needs.  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 monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve removal of torus mandibularis (D7473), and removal of torus palatinus (D7274 x 2).  You asked the Plan to pre-approve the dental services. You say that you need these services so that your dentures will fit. You also say that you cannot afford these procedures. The Plan denied your request. The Plan says removal of torus mandibulari is not listed as a covered service. The Plan says that removal of torus palatinus is not listed as a covered service either.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested dental services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve removal of torus mandibularis (D7473), and removal of torus palatinus (D7274 x 2).
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the F2 gene testing (81240) and F5 gene testing (81241).  You asked the Plan to pre-approve the genetic testing services. You say that these genetic testing services are medically reasonable and necessary. The Plan denied your request. The Plan says this is not a covered service according to Medicare rules.  The Plan must follow Medicare rules. Medicare rules say that F2 and F5 gene testing services are non-covered except for pregnant patients.  We looked at the file and Medicare rules. In this case, you do not have a covered indication for the requested genetic testing services. Based on this information, we decided that Medicare rules for coverage of the genetic testing services have not been met. Therefore, we decided that the Plan does not have to pre-approve the F2 gene testing (81240) and F5 gene testing (81241).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve physical therapy services to be provided by the requested out-of-network provider.  You asked the Plan to pre-approve physical therapy services to be provided by the Physical Therapy facility. You say that this facility is very close to your home. The Plan denied your request. The Plan says the member's needs can be met in-network therefore, going out of network is not medically necessary at this time.  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 physical therapy services to be provided by the requested out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a chair/staircase elevator.  You asked the Plan to pre-approve the lift. You say that this is medically necessary. The Plan denied your request. The Plan says this is a non-covered item.  The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they are not primarily medical in nature.   While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a chair/staircase elevator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve crowns (D2751) for teeth #18 and #19 to be provided by an out-of-network provider.  You asked the Plan to pre-approve out-of-network dental care. You say that these services are necessary. The Plan denied your request. The Plan says this provider is not part of the Plan's dental network, and out-of-network dental care is not covered.  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 requires that supplemental dental services be performed by a participating provider.  Though the Plan offers a dental benefit in excess of Medicare coverage, items or services received out-of-network are not covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve crowns (D2751) for teeth #18 and #19 to be provided by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve abutment services (D6057 and D6059) to be provided by a participating provider.  You asked the Plan to pre-approve abutment services. You say that you would like the Plan to approve these services. The Plan denied your request. The Plan says the requested dental service is not a covered benefit.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve abutment services (D6057 and D6059) to be provided by a participating provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Dyansys Auricular neurostimulator coded as (64555, L8679).  You asked the Plan to pre-approve Dyansys Auricular neurostimulator. You say that the enrollee has tried and failed conservative care and medication therapies. Based on history and diagnoses, the provider is recommending the neurostimulator to decrease pain. The Plan denied your request. The Plan says this service is not a covered Medicare benefit because acupuncture for auricular stimulation does not meet the definition of reasonable and necessary.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.   We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Dyansys Auricular neurostimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve Dyansys Auricular neurostimulator coded as (64555, L8679).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a custom ramp.  You asked the Plan to pre-approve the ramp. You say that this is medically necessary. The Plan denied your request. The Plan says there is no mention of home dialysis in the medical history.  The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home.   The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pre-approve a custom ramp.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an expandable controller (E2377) with harness (E2313) and electronic connection (E2311) for a power wheelchair.  You asked the Plan to pre-approve an expandable controller with harness and electronic connection. You say that the requested items are a medical necessity for the enrollee. The Plan denied your request. The Plan says medical necessity rules for the requested items 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 an expandable controller with harness and electronic connection. Our reviewer says that the requested items are not considered medically reasonable and necessary in this case. Our physician reviewer found that there is no documentation that the expandable controller E2377, harness E2313, and electronic connection E2311 meet Medicare criteria for medical necessity and reasonableness for the enrollee in this case. Provided records document that the enrollee has 3/5 to 5/5 upper extremity strength and is able to eat and groom self with set up assistance, thus indicating the enrollee has adequate upper extremity strength and function to operate the wheelchair's power options with 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 expandable controller with harness and electronic connection have not been met. Therefore, we decided that the Plan does not have to pre-approve an expandable controller (E2377) with harness (E2313) and electronic connection (E2311) for a power wheelchair.
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 is broken into two pieces. The Plan denied your request. The Plan says this service is allowed one time every 60 months. The Plan also says that you have received this service less than 60 months ago.  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, dentures are limited to one set every 5 years. The record shows that you received a complete maxillary denture (D5110) on July 12, 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: 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 need ongoing medical care and skilled therapy in an inpatient setting before you can return home safely. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. You can safely receive the services you need in an alternate setting.  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 that the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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. There is not a reasonable expectation that you 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: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for a pneumatic compression device (E0673, E0675) on May 28, 2021.  You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the claim was not billed as required by coding regulations.  The Plan must follow Medicare rules. The Plan must follow Medicare rules. Medicare rules say that a pneumatic compression device (E0675) to treat peripheral artery disease is not eligible for reimbursement.   The requested device (E0675) and accessory (E0673) are statutorily not covered by Medicare. Based on this information, we decided that Medicare rules for coverage of the services have not been met.  Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0673, E0675) on May 28, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Injectafer for the enrollee.  You asked the Plan to pre-approve Injectafer. You say that this is medically necessary to treat the patient's iron deficiency anemia. The Plan denied your request. The Plan says that the member has not tried and failed the preferred step therapy drugs.  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 Injectafer. Our reviewer says that Injectafer is not medically reasonable and necessary for the enrollee. The patient has not tried and failed Infed (iron dextran) and Venofer (iron sucrose). There is no documentation provided indicating that the plan's required drugs would likely be less effective and/or likely have adverse effects for the enrollee. Our physician reviewer found that the enrollee's condition does not meet step therapy criteria for Injectafer.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Injectafer have not been met. Therefore, we decided that the Plan does not have to pre-approve Injectafer for the enrollee.