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

We decided that the Plan does not have to pre-approve a partial upper denture (D5225).
You asked the Plan to pre-approve the denture. You say that you have a previous denture which is getting old and needs to be replaced at this point. The Plan denied your request. The Plan says dentures are not covered by your dental benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested 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 upper denture (D5225).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network provider at the in-network rate.
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 available from network providers at the in-network rate.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $65 copayment for out-of-network specialist's office services.
You are requesting services with an out-of-network ophthalmologist. If you choose to receive services with this provider, you will be asked to pay a $65 copayment for these services. These services fall within the out-of-network specialist's office services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. The Plan has network providers that can provider services at the in-network rate. Therefore, we decided that the Plan does not have to pre-approve a referral to an out-of-network provider at the in-network rate.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve MyoPro Motion G Orthotic device (L8702).
You asked the Plan to pre-approve the MyoPro device. You say that the claim should be paid. The Plan denied
your request. The Plan says the device is not covered.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We asked our 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 MyoPro device. Our reviewer says that the
requested items/services are not considered reasonable and necessary in this case. Our reviewer found devices
that experimental and investigational devices are not covered.
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 MyoPro device have not been met. Therefore, we decided that the Plan does
not have to pre-approve MyoPro Motion G Orthotic device (L8702).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the high frequency chest wall oscillation device (HFCWOD) (E0483).
You asked the Plan to pay for the HFCWOD. You say that with a diagnosis of COPD, the enrollee will continue to be at high risk for chronic illness and ever escalating healthcare costs for the rest of his life. The Plan denied your request. The Plan says you do not have a qualifying diagnosis and therefore does not meet the coverage criteria.
The Plan must follow Medicare rules. Medicare rules say the HFCWODs are covered only when they are medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases.
The record does not show that you have cystic fibrosis, bronchiectasis, or a covered neuromuscular disease. This means that you do not have a medical condition for which a high frequency chest wall oscillation devise can be covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for the high frequency chest wall oscillation device (HFCWOD) (E0483).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve services to be provided by an out-of-network provider.
You asked the Plan to pre-approve services to be provided by an out-of-network provider. You say that your labs are being sent to this provider. The Plan denied your request. The Plan says the requested services can be provided by a network provider.
The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services, plans are not required to make payments for any services received by enrollees that are not provided directly by the Plan or through arrangements made by the Plan. The services at issue in this appeal will not be provided in an emergency or urgent care situation. The Plan is not providing these services and is not making arrangements to provide these services. Therefore, we decided that the Plan does not have to pre-approve services to be provided by an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

You asked the Plan to pre-approve acute inpatient hospital 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 inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient admission are met in this 
case. Our physician reviewer found the record does not document that the treating physician has a reasonable 
expectation of a length of stay spanning 2 or more midnights. The enrollee may be admitted for observation. 
The elements of the coverage rule are not satisfied. The requested service is not recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital 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 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 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 the enrollee does not require the intensity of services provided at an IRF.
Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's 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: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve neuropsychological testing evaluation services (96132).
You asked the Plan to pre-approve neuropsychological testing services. You say that this test is medically necessary. The Plan denied your request. The Plan says this test does not meet the Medicare criteria for coverage and cannot be found medically necessary and reasonable in this case.
The Plan follows Medicare rules. Medicare rules say that a psychiatric diagnostic procedure requires the elicitation of a complete medical (including past, family, social) and psychiatric history, a mental status examination, establishment of an initial diagnosis, an evaluation of the patient's ability and capacity to respond to treatment, and an initial plan of treatment. Information may be obtained from not only the patient, but also
other physicians, healthcare providers, and/or family if the patient is unable to provide a complete history. 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 neuropsychological testing services. Our reviewer says that the requested service is not medically necessary. Our physician reviewer found the documentation does not include the anticipated goals of the testing, nor does it demonstrate that the testing is reasonably expected to improve the enrollee's condition or to reduce or control the enrollee's psychiatric symptoms so as to prevent relapse or hospitalization and improve or maintain the enrollee's level of functioning. The requested neuropsychological testing evaluation is not considered reasonable or necessary for the enrollee in this case. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of neuropsychological testing services have not been met. Therefore, we decided that the Plan does not have to pre-approve neuropsychological testing evaluation services (96132).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable oxygen concentrator.
You asked the Plan to pre-approve you disagree with the denial.. You say that you need a replacement because
your current portable device heats up. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that replacement durable medical equipment (DME)
is covered in the case of irreparable wear or when it has exceeded the reasonable lifetime period of five years.
We looked at the file and Medicare rules. The file shows that the current portable oxygen concentrator is not
more than five years old or irreparably damaged. A replacement unit is therefore not covered. Therefore, we
decided that the Plan does not have to pre-approve a portable oxygen concentrator.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve testosterone cypionate.
You asked the Plan to pre-approve testosterone cypionate. You say that the medication is necessary. The Plan denied your request. The Plan says the enrollee has a medical only policy which does not include Part D prescription coverage, therefore the criteria for self-administered drug coverage has not been met.
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 testosterone cypionate.
Benefits for testosterone cypionate 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the consultation and deep sedation.
You asked the Plan to pre-approve the consultation and deep sedation. You say that you were to have extractions done with immediate placement. The Plan denied your request. The Plan says the claim reprocessed to approve the extractions and erupted tooth root removal. The consultation and deep sedation remain denied as non-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 consultation and deep sedation.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does not meet criteria.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee appears to be improving, stable, and should only require short-term additional acute care services that can safely be provided at the current facility. There are no services at the LTACH that the enrollee requires that are not already available and covered at the current facility. Transfer to a lower level of care may be considered when treatment has completed.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a full cast noble metal crown (D2792) for tooth #31.

You asked the Plan to pre-approve the crown. You say that the enrollee had a crown provided on this tooth at a different office, but this crown now has a hole and needs replaced. The Plan denied your request. The Plan says they previously paid for a crown on this tooth less than five years ago. This service can only be covered once per tooth every five 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. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the crown is requested in a frequency that is not covered under this benefit. Documentation shows that the enrollee previously had a crown on tooth #31 provided and paid for less than five years ago. Therefore, we decided that the Plan does not have to pre-approve a full cast noble metal crown (D2792) for tooth #31.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the SNF services.
You asked the Plan to pre-approve the SNF services. You say that you would like reconsideration because the SNF services are medically necessary. The Plan denied your request. The Plan says you do not meet Medicare coverage criteria for the SNF services.
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 the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the documentation does not support that it is medically reasonable and necessary to provide skilled therapy services to you in this case on a "daily basis" in a skilled nursing facility on an inpatient basis. Your needs can be met 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve the SNF services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex Superion spacer. 
 
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 Superion spacer 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 Vertiflex Superion spacer.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve large joint/joint capsule injection (Euflexxa) for the 
enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no evidence of at least six weeks of physical therapy or a home exercise 
program. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 the services. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found there is no 
documentation of x-ray results, and no mention of any conservative therapy, such as physical therapy or a 
home exercise program. The review has determined that the documentation does not support that the requested 
injection is safe, effective, reasonable, or 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve large joint/joint capsule injection (Euflexxa) for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the parathyroid planar imaging (78071).

You asked the Plan to pre-approve the parathyroid scan. You say that a parathyroid scan has been ordered due to the enrollee's elevated parathyroid hormone which is not concordant with her level of renal disease. The Plan denied your request. The Plan says the records do not support that you meet the criteria for the requested parathyroid scan.

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 the parathyroid scan. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the diagnosis of hyperparathyroidism has not been established by lab testing and the parathyroid scan is not reasonable or medically necessary. The diagnosis of primary hyperthyroidism with non-elevated serum calcium requires either an elevated ionized serum calcium or an elevation of historic calcium levels and also requires that additional investigation be done for secondary causes of hyperparathyroidism including renal insufficiency, and Vitamin D deficiency. The review has determined that the requested parathyroid scan is not medically reasonable or 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 the parathyroid scan have not been met. Therefore, we decided that the Plan does not have to pre-approve the parathyroid planar imaging (78071).
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Genvisc.
You asked the Plan to pre-approve Genvisc. You say that the medication is necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has 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 Genvisc. Our reviewer says that the medication is not medically necessary. Our physician reviewer found the record does not indicate that the enrollee has a contraindication to or would have an adverse effect from the plan's preferred step one alternative. The elements of the coverage criteria are not satisfied. The requested service cannot be recommended. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Genvisc have not been met. Therefore, we decided that the Plan does not have to pre-approve Genvisc.