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

We decided that the Plan does not have to pre-approve Freestyle Lite test strips.
You asked the Plan to pre-approve the Freestyle Lite test strips. You say that the requested test strips are medically necessary. The Plan denied your request. The Plan says the criteria for coverage of diabetic supplies from a non-preferred provider have not been met.
The Plan must follow Medicare rules. Medicare rules say that Plans may specify brands and manufacturers as preferred and may limit the DME to only those preferred brands and manufacturers as long as the enrollee retains access to all medically necessary items. We looked at the file and Medicare rules. The records provided do not demonstrate that the Plan's preferred brand of testing strips would not be sufficient. The records did not demonstrate that it is medically necessary to use the non-preferred brand for the enrollee's diabetic testing strips. Based on this information, we decided that Medicare rules for coverage of the Freestyle Lite test strips have not been met. Therefore, we decided that the Plan does not have to pre-approve Freestyle Lite test strips
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Monovisc injection for the enrollee.
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says there is no record from the prescriber that shows a trial of the preferred 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 the injection. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found based on the medical records, the enrollee has not tried and failed the required drugs. There is no indications that these drugs would likely be less effective and/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 the injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a Monovisc injection for the enrollee
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuation of skilled nursing facility (SNF) services.

You asked the Plan to pre-approve a continuation of SNF care. You say that the SNF level of care is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet the criteria for a continued SNF stay.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a continuation of SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral medications and had stable vital signs. The enrollee received physical therapy and occupational therapy in the SNF. By the dates in question, she was at a contact guard assist level with functional mobility, including gait to 100 feet. The enrollee required varying assist with activities of daily living. There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not meet the severity of illness or intensity of service criteria for an inpatient basis in a SNF setting. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a continuation of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuation of skilled nursing facility (SNF) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve pontics and retainer crowns.
You asked the Plan to pre-approve pontics and retainer crowns. You say that you feel these services should be covered. The Plan denied your request. The Plan says the requested dental services are 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 pontics and retainer crowns.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a maxillary partial denture (D5225).
You asked the Plan to pre-approve the maxillary partial denture. You say that you need this denture for your health and so you can eat. The Plan denied your request. The Plan says this service 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. 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 (D5225).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that the enrollee will benefit from having extended
rehabilitation services at a short-term skilled care facility. The Plan denied your request. The Plan says there
are no additional services at a SNF which are not available at the intensive rehabilitation facility when the
enrollee is currently receiving care.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve SNF services. Our physician reviewer
found that the enrollee is at a contact guard assist level for bed mobility, transfers, and activities of daily living.
Functionally, she is doing well with intensive rehabilitation facility (IRF) therapies. She has no daily skilled
nursing needs. The documentation does not support the need for an admission to a skilled nursing facility.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not
have to pre-approve skilled nursing facility (SNF) services
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a partial lower denture (D5214).
You asked the Plan to pre-approve the denture. You say that your previous denture is not able to be repaired and needs to be replaced as it was not made correctly. The Plan denied your request. The Plan says You previously received this type of denture in July of 2020 from a different provider. This type of denture can only be covered once every five plan years.
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 can cover one D5214
lower partial denture every five plan years. Though the Plan offers a dental benefit in excess of Medicare coverage, the denture is requested in a frequency that is not covered under this benefit. Documentation shows that you previously received this type of denture in July 2020. Therefore, we decided that the Plan does not have to pre-approve a partial lower denture (D5214).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve four gingival irrigations (D4921 x4).

You asked the Plan to pre-approve the gingival irrigations. You say that you are experiencing slight pain and would like these procedures to be covered. The Plan denied your request. The Plan says this service is not covered under your benefit package.
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 four gingival irrigations (D4921 x4).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the upper partial denture (D5213).
You asked the Plan to pre-approve the dental services. You say that when you wear your dentures you
immediately start gagging. The dentures sustained possible mechanical trauma and you feel that replacement of
the dentures is necessary warranted and should be allowed. The Plan denied your request. The Plan says this
request exceeds the benefit frequency limitation.
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. Per page 4-63 of the EOC, the
Plan cover's this service once every 5 years. The records show this service was provided February 7, 2019.
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
upper partial denture (D5213).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a dental extraction with an oral surgeon.
You asked the Plan to pre-approve the extraction. The Plan denied your request. The Plan says this 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 services are not among
those covered under this benefit when performed by an oral surgeon. The Plan requires dental services to be
performed by a general dentist. Therefore, we decided that the Plan does not have to pre-approve a dental
extraction with an oral surgeon.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a total electric hospital bed (E0265).
You asked the Plan to pre-approve a total electric hospital bed. You say that the requested item is a medical
necessity for you. The Plan denied your request. The Plan says rules for coverage have not been met because
the requested item is not a benefit of Medicare or the Plan.
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital
bed (E0265).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the endodontic therapy (D3330).
You asked the Plan to pre-approve the endodontic therapy. The Plan denied your request. The Plan says this service 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. 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 endodontic therapy (D3330).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a total electric hospital bed with side rails (E0265).
You asked the Plan to pre-approve a total electric hospital bed. You say that the requested item is a necessity for your care. The Plan denied your request. The Plan says rules for coverage have not been met because the requested item is not a benefit of Medicare or the Plan.
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered. While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital bed with side rails (E0265).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the upper and lower partial denture (D5213 and D5214).
You asked the Plan to pre-approve the upper and lower partial denture (D5213 and D5214). You say that the tooth broke off and you need a new partial. The Plan denied your request. The Plan says the service is only allowed one time every 60 months.
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 upper and lower partial denture every 60 months. The Plan paid for an upper and lower partial denture provided on March 1, 2019, which exhausted your benefit. Therefore, we decided that the Plan does not have to pre-approve the upper and lower partial denture (D5213 and D5214).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a partial denture.
You asked the Plan to pre-approve a partial denture. You say that you feel this item should be covered. The Plan denied your request. The Plan says the requested item 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 a partial denture.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the beneficiary does not require skilled nursing or therapy services on a daily basis. This beneficiary does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
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 enrollee meets criteria for IRF care. The Plan denied your request. The Plan says criteria for admission to the IRF setting 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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical problems are stable. There are no complex nursing or rehabilitation needs. 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 this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Minuteman procedure.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has lumbar spinal stenosis. The requested Minuteman procedure is considered experimental in nature, as more research is needed to show safety and efficacy. The services are therefore 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 a Minuteman procedure
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill.
You asked the Plan to pre-approve special supplemental benefits. You say that you have some chronic conditions and feel these benefits would help you. The Plan denied your request. The Plan says you do not meet the eligibility criteria for this supplemental benefits package.
Medicare does not cover the services provided in the Plan's supplemental benefits package. Because the Plan offers extra coverage for services that are not covered by Medicare, the Plan's coverage rules apply in this case. The Plan provides these benefits to enrollees who suffer from one or more comorbid and medically complex chronic conditions that are life-threatening or that significantly limit the enrollee's health or general functioning. Enrollee's must also have a high risk of hospitalization or other adverse health outcomes and must require intensive care coordination. Specific eligible chronic conditions are listed in the Plan's contract. The Plan's rules for eligibility for special supplemental benefits package have not been met. While you may have some chronic conditions, your physician has indicated that you do not have any of the conditions indicated as eligible by the Plan. In addition, your physician has also indicated that you do not require intensive care coordination and you do not have a high risk of hospitalization or other adverse health outcomes. The Plan's rules for coverage have not been met in this case. Therefore, we decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve endodontic therapy for tooth #'s 20 and 21.
You asked the Plan to pre-approve endodontic therapy. You say that you haven't used your dental services in the last three years and the root canal was denied the one time you try to use it. The Plan denied your request. The Plan says the services are not covered 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 endodontic therapy for tooth #'s 20 and 21.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the pontic (D6241) and retainer crowns (D6751).

You asked the Plan to pre-approve the pontic (D6241) and retainer crowns (D6751). You say that the missing teeth makes it hard to chew and limits you smiling and talking. You say that this is what the dentist recommended as the best solution for you. The Plan denied your request. The Plan says the services are not covered 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 pontic (D6241) and retainer crowns (D6751).