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

We decided that the Plan does not have to pre-approve a complete lower denture (D5120).
You asked the Plan to pre-approve the dental item. You say that your puppy ate your denture. You say that you are depressed due to not being able to eat. You say that your gums are sore, and your jaws have popping. You also say that you need a new one. The Plan denied your request. The Plan says 1 complete lower denture is covered once every 5 plan years. The Plan also says that the frequency limit has been reached.
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. We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental item have not been met. Specifically, the frequency limit has been reached. The record shows that the Plan paid for a complete lower denture that you received on December 19, 2020. Therefore, we decided that the Plan does not have to pre-approve a complete lower denture (D5120).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve implantable neurostimulator and percutaneous implantation of neurostimulator electrode array services.
You asked the Plan to pre-approve implantable neurostimulator and percutaneous implantation of neurostimulator electrode array services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.
The Plan follows Medicare rules. Medicare rules say that implantable neurostimulators are only covered for certain indications. 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 implantable neurostimulator and percutaneous implantation of neurostimulator electrode array services. Our reviewer says that the documentation does not support that the requested services are medically reasonable or necessary. Our physician reviewer found the enrollee has lumbar spinal stenosis with neurogenic claudication and lumbar radiculopathy. The requested therapy of placement of the DyAnsys auricular pulse generator is not evidence based and the items effectiveness has not been proven for the pain of lumbar spinal stenosis. Therefore, the enrollee does not meet criteria for the requested services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of implantable neurostimulator and percutaneous implantation of neurostimulator electrode array services have not been met. Therefore, we decided that the Plan does not have to pre-approve implantable neurostimulator and percutaneous implantation of neurostimulator electrode array services
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a seat lift chair and mechanism.
You asked the Plan to pre-approve a seat lift chair and mechanism. You say that The Plan denied your request. The Plan says
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all the conditions listed are met. Medicare does not cover the upholstered chair often sold with the seat lift mechanism. The enrollee does not meet the criteria required to have the seat lift mechanism covered by itself. Therefore, we decided that the Plan does not have to pre-approve a seat lift chair and mechanism.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an oral device/appliance used to reduce upper airway collapsibility, adjustable or non-adjustable, custom fabricated, including fitting and adjustment (E0486) to be rendered by the out-of-network (OON) provider.
You asked the Plan to pre-approve this item. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says there are in-network providers available to render the requested item.
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 item at issue in this appeal. We found no exception that would require the Plan to pre-approve this item. Therefore, we decided that the Plan does not have to pre-approve an oral device/appliance used to reduce upper airway collapsibility, adjustable or non-adjustable, custom fabricated, including fitting and adjustment (E0486) to be rendered by the out-of-network (OON) provider
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (PCD) described by code E0652 with full leg sleeve.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the criteria for coverage are not met.
The Plan must follow Medicare rules. The rules say that an E0652 PCD is covered when there is a documented four week trial of an E0651 PCD. We looked at the file and Medicare rules. The file shows that the enrollee did not have a four week trial of the basic pump described by code E0651. 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 pneumatic compression device (PCD) described by code E0652 with full leg sleeve
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips.
You asked the Plan to pre-approve additional routine transportation trips. You say that additional routine transportation trips are necessary. The Plan denied your request. The Plan says once this benefit is exhausted it cannot be extended.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 24 trips per year. Medicare does not make exceptions for supplemental benefits. Once this benefit is exhausted it cannot be extended. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation trips
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation feature 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 a power seat elevation feature (E2300) and power standing feature (E2301) are non-covered because they are not primarily medical in nature. We looked at the file and Medicare rules. The requested power seat elevation system is not covered by Medicare. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation feature for a power wheelchair (PWC).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ten (10) visits of land-based and water-based physical therapy.
You asked the Plan to pre-approve ten (10) visits of land-based and water-based physical therapy. The Plan denied your request. The Plan says based on the clinical guidelines used, land-based physical therapy and water based physical therapy are not usually done at the same time.
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) visits of land-based and water-based physical therapy. 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 in this case, the enrollee has previously been treated with outpatient therapies and should be independent with a home exercise program. There is no documentation of a recent injury or decline in function. The additional therapy services are not an appropriate duration and frequency for treatment of the enrollee's medical condition and therefore 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 ten (10) visits of land-based and water-based physical therapy. have not been met. Therefore, we decided that the Plan does not have to pre-approve ten (10) visits of land-based and water-based physical therapy.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve transthoracic echocardiography, real-time with image documentation (2D), includes M-mode recording, when performed (93306).
You asked the Plan to pre-approve transthoracic echocardiography. You say that you need the ECHO because you had surgery and they need to monitor your heart. The Plan denied your request. The Plan says that the records do not support that the services are medically necessary.
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 transthoracic echocardiography. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has a history of severe mitral valve disease and is status post a mitral repair. Although asymptomatic, a yearly or every two-year assessment of recurrent mitral insufficiency and LV function by transthoracic echo prior to any asymptomatic deterioration is medically reasonable and necessary in this clinical situation. This meets the applicable CMS LCD 33577 criteria noted below based on the medical history of severe mitral valve disease, the clinical situation and the clinician's judgement. From LCD 33577: Absent acute intervention, or a discrete change in otherwise stable clinical signs and symptoms, it is not medically necessary to repeat these examinations more frequently than annually. When the patient's clinical status shows evidence of change or the plan of care includes consideration for imminent valvular surgery, more frequent exams may be 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 transthoracic echocardiography have been met. Therefore, we decided that the Plan has to pre-approve transthoracic echocardiography, real-time with image documentation (2D), includes M-mode recording, when performed (93306).
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued negative pressure wound therapy (NPWT).
You asked the Plan to pre-approve continued negative pressure wound therapy. You say that you would like
the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not a
covered benefit.
The Plan must follow Medicare rules. Medicare rules say that negative pressure wound therapy is only covered
for four months.
We looked at the file and Medicare rules. Review of the file shows that the enrollee has used this device for the
past four months. The request is for month five. Based on this information, we decided that Medicare rules for
coverage of continued negative pressure wound therapy have not been met. Therefore, we decided that the Plan
does not have to pre-approve continued negative pressure wound therapy (NPWT).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a personal alert or life alert system for the enrollee.

You asked the Plan to pre-approve precautionary alert equipment of any kind. You say that a personal alert system is necessary for the enrollee. The Plan denied your request. The Plan says this equipment is not covered by Medicare.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. Personal alert systems do not serve a purpose that is primarily medical in nature. This equipment is precautionary in nature. This equipment is available to the 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 personal alert or life alert system for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on February 28, 2020.

You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.

We looked at the file and Medicare rules. In this case, the claim was billed with an incorrect place of service (POS) code per Medicare guidelines. The records show that the specimen was obtained in an office setting. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on February 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an out-of-network referral for dental consultations.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says in-network providers must be used.
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, as they are not to be provided by an in-network provider. Therefore, we decided that the Plan does not have to pre-approve an out-of-network referral for dental consultations
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the pontic and retainer crowns for a fixed bridge and core buildup.

You asked the Plan to pre-approve the pontic and retainer crowns for a fixed bridge and core buildup. You say that your front tooth became loose and completely dislodged. You say that you want the crown for the current missing tooth or a partial denture. The Plan denied your request. The Plan says the 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 the pontic and retainer crowns for a fixed bridge and core buildup.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa (J7323).
You asked the Plan to pre-approve Euflexxa. You say that this is medically necessary. The Plan denied your request. The Plan says step therapy requirements have not been met.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain
Part B medications. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Euflexxa. Our reviewer says that the requirements for coverage of Euflexxa have not been met. Our physician reviewer found the Plan requires a trial of Orthovisc and Monovisc before they will approve the requested drug. In this case, the patient has not tried and failed the required drugs. There is no documentation provided indicating that the plan's required drugs would likely be less effective or likely 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 Euflexxa have not been met. Therefore, we decided that the Plan does not have to pre-approve Euflexxa (J7323).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the LINX reflux management procedure.
You asked the Plan to pre-approve the LINX reflux management procedure. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that the LINX procedure is not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LINX reflux management procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the LINX reflux management procedure
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a suction-assisted lipectomy with a lymphovenous bypass to be rendered by the out-of-network (OON) provider.

You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says there are in-network providers available to render the requested service.

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 service at issue in this appeal. We found no exception that would require the Plan to pre-approve this service. Therefore, we decided that the Plan does not have to pre-approve a suction-assisted lipectomy with a lymphovenous bypass to be rendered by the out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the additional extractions and residual tooth root removal.
You asked the Plan to pre-approve the additional extractions and residual tooth root removal. You say that this is medically necessary to repair teeth after a fall. You say that you were promised the dental issues would be covered by the Plan. The Plan denied your request. The Plan says only one extraction is covered per calendar year and the residual tooth root removal 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, you also have a maximum benefit of one extraction per calendar year. The Plan previously approved one extraction, which exhausted your benefit. The residual tooth root removal remains denied as a non-covered benefit. Therefore, we decided that the Plan does not have to pre-approve the additional extractions and residual tooth root removal.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied
your request. The Plan says the criteria for coverage are not met.
The Plan must follow Medicare rules. Medicare rules say that 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 treat with
insulin three or more times per day or use an insulin pump.
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 continuous glucose monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve wheelchair accessories (E1002, K0108, E2617, E2609).
You asked the Plan to pre-approve the wheelchair accessories. You say that the items are medically necessary. The Plan denied your request. The Plan says coverage rules are not met.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home. Records show that the wheelchair accessories are being requested for use in a SNF or hospital. Therefore, we decided that the Plan does not have to pre-approve wheelchair accessories (E1002, K0108, E2617, E2609).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bone growth stimulator for the enrollee.

You asked the Plan to pre-approve a bone growth stimulator. You say that a bone growth stimulator is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met.

The Plan must follow Medicare rules. The rules say that an electrical bone growth stimulator is covered for nonunion of long bone fractures. In this case, nonunion of a long bone fracture is not considered to exist under Medicare rules. The bone fracture indicated in the records is a short bone fracture. The enrollee does not meet the criteria needed to the use of this device to be covered by Medicare. Therefore, we decided that the Plan does not have to pre-approve a bone growth stimulator for the enrollee.