Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).

You asked the Plan to pre-approve admission to a SNF. You say that the requested admission to a SNF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF admission.

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 admission to a SNF. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment in a SNF. The documentation does not reveal evidence of complex wound care, new enteral feedings, or other skilled nursing SNF need. The enrollee's high functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment in a SNF. The enrollee does not require skilled nursing or skilled therapy services (or a combination of these services) on a daily basis in a SNF. As a practical matter this enrollee does not require the necessary services on an inpatient basis, in a skilled nursing facility setting. The enrollee currently is having her ammonia level monitored per the January 11, 2021 progress note and is being treated with lactulose. Her current condition can be safely and effectively managed in the current setting until she is ready for home or community discharge. There is no evidence that she requires a transfer to a SNF for skilled nursing or therapy at this time. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of admission to a SNF have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve a crown porcelain/ceramic (D2740) on tooth #14.

You asked the Plan to pre-approve a crown. You say that the original tooth was cracked. The provider advised that a filling would not correct the issue because the tooth was too damaged. A low-quality crown was installed, and it scratches like sandpaper both inside and outside. You also say you visited another dentist and they tried to make it smoother, and it did not work. The Plan denied your request. The Plan says that the existing crown was placed eight months ago, and you reached your benefit limitation of one crown per tooth 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. 

We looked at the file and Medicare rules. The EOC confirms that a crown (D2740) is listed as a covered benefit. The Plan has not submitted any documentation showing that a crown is covered once every 60 months. Based on this information, we decided that the Plan's rules for coverage of a crown have been met. Therefore, we decided that the Plan has to pre-approve a crown porcelain/ceramic (D2740) on tooth #14.

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 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 you do not treat with insulin. 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a mandibular partial denture (D5214).

You asked the Plan to pre-approve the mandibular partial denture. You say that you would like your current partial to be replaced because it is broken. The Plan denied your request. The Plan says this service exceeds the maximum count allowed per period.

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, mandibular partial denture (D5214) is limited to one procedure every five plan years. The record shows that you received a mandibular partial denture (D5214) on January 30, 2018 and your mandibular partial denture (D5214) benefit has been exhausted. Therefore, we decided that the Plan does not have to pre-approve a mandibular partial denture (D5214).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Intracept procedure (22899, C9752).

You asked the Plan to pre-approve an Intracept procedure. You say that other treatments have not helped. The
Plan denied your request. The Plan says this is experimental.

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 Intracept procedure. Our reviewer
says that the requested services are not considered medically reasonable and necessary in this case. Our
physician reviewer found the Intracept procedure is experimental. More research is needed to show it is safe
and effective.

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 Intracept procedure have not been met. Therefore, we decided that the Plan
does not have to pre-approve an Intracept procedure (22899, C9752).
Appeal type: Step-Therapy
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Truxima.  

You asked the Plan to pre-approve Truxima. You say that the requested Truxima is medically necessary. The Plan denied your request. The Plan says the enrollee must try and fail Fituxan, Ruxience, or Riabni first.  

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 Truxima. Our reviewer says that the Plan's step therapy criteria have not been met. Our physician reviewer found the record indicates that the enrollee has mantle cell lymphoma.  The requested medication is a new start.  The provided records do not indicate that the enrollee has tried and failed the plan's preferred step one alternative. 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 Truxima have not been met. Therefore, we decided that the Plan does not have to pre-approve Truxima.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve periodontal scalings and root planings (D4341) for all four quadrants.  

You asked the Plan to pre-approve the scalings and planings. The Plan denied your request. The Plan says this service is not covered under your benefit plan.  

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve periodontal scalings and root planings (D4341) for all four quadrants.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a vertebroplasty (22513).  

You asked the Plan to pre-approve the vertebroplasty. You say that the procedure is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.  

The Plan follows Medicare rules. Medicare rules say that Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF) is covered when medically necessary and not contraindicated.  

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 vertebroplasty. Our reviewer says that the requested procedure is not medically necessary. Our physician reviewer found the record indicates that has an acute osteoporotic compression fracture with greater than 50% vertebral height reduction. The record does not indicate the presence of progression of height loss, Kyphotic deformity, or Severe impact of VCF on daily functioning. The record does not indicate that the enrollee has been referred for osteoporotic risk reduction or education. The record indicates the presence of retropulsion of a fracture fragment. The procedure is not supported by the records.  

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 vertebroplasty have not been met. Therefore, we decided that the Plan does not have to pre-approve a vertebroplasty (22513).
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 this is medically necessary. The Plan denied your request. The Plan says your needs can be met in a different setting.

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 at this time you do not require skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis" in a SNF. As a practical matter, you do not require services on 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: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve alveoloplasty procedures (D7310) and intravenous sedation/analgesia (D9239, D9243).  You asked the Plan to pre-approve the dental services. You say that you have had this plan for years and have had dental care covered in the past. The Plan denied your request. The Plan says these services 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 alveoloplasty procedures (D7310) and intravenous sedation/analgesia (D9239, D9243).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a power seat elevation system.  

You asked the Plan to pre-approve 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) is non-covered.  

We looked at the file and Medicare rules. The item at issue is a power seat elevation system. This item is not covered by Medicare. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation system.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652).  You asked the Plan to pre-approve a pneumatic compression device. You say that the pneumatic compression device is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.  The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required.  We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (E0652).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an incisional biopsy of oral tissue (D7286).  

You asked the Plan to pre-approve the incisional biopsy. You say that you need this service to be approved. The Plan denied your request. The Plan says this service is not covered under your benefit plan.  

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an incisional biopsy of oral tissue (D7286).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve periodontal scalings and root planings (D4341) for each quadrant.

You asked the Plan to pre-approve the scalings and planings. 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 periodontal scalings and root planings (D4341) for each quadrant.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the scaling and root planing services

You asked the Plan to pre-approve the scaling and root planing services. You say that you would like
reconsideration because this dentist is in-network. The Plan denied your request. The Plan says the requested
services are not medically necessary.

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 covers the scaling
and root planing services when the services are medically necessary and reasonable.

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 scaling and root planing services.
Our reviewer says that the supplied records indicate probing depths of up to 6mm in the right quadrants and
one in the upper left. The supplied radiographs do indicate a notable one loss around teeth #s 2, 3, and 31 but
not around any other teeth. Our physician reviewer found in this instance there are three teeth in total with
notable bone loss, two in the upper right quadrant and one in the lower right. CDT code D4341 is reserved for
situations where there are four or more teeth in a quadrant that are involved with accessible root surfaces due to
bone loss. In this instance there are two involved teeth in the upper right and one in the lower left quadrants. A
lesser code for periodontal treatment should be used for those areas. Given the presentation of the case, there is
no necessity for the requested scaling and root planing under D4341 coding.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
the Plan's rules for coverage of the scaling and root planing services have not been met. Therefore, we decided
that the Plan does not have to pre-approve the scaling and root planing services
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the FreeStyle Libre Continuous Glucose Monitor (CGM).

You asked the Plan to pre-approve the FreeStyle Libre CGM. You say that you would like reconsideration because the member's condition is unmanaged. The Plan denied your request. The Plan says the member does not meet Medicare coverage criteria for the requested CGM.

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 FreeStyle Libre CGM. Our reviewer says that the beneficiary is not insulin-treated with multiple (three or more) daily administrations of insulin or a Medicare-covered continuous subcutaneous insulin infusion (CSII) pump. Our physician reviewer found the beneficiary's insulin treatment regimen does not require frequent adjustment. 

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 FreeStyle Libre CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve the FreeStyle Libre Continuous Glucose Monitor (CGM).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolaris prostate cancer assay.

You asked the Plan to pre-approve Prolaris prostate cancer assay. You say that the requested Prolaris prostate cancer assay is medically necessary. The Plan denied your request. The Plan says the requested Prolaris prostate cancer assay is 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 Prolaris prostate cancer assay. Our reviewer says that the requested Prolaris prostate cancer assay is not medically necessary. Our physician reviewer found per National Comprehensive Cancer Network (NCCN) guidelines (3/2022 page MS-70), Polaris is only covered for very low, low and favorable intermediate risk prostate cancer who are candidates for active surveillance versus definitive treatment. The request is not medically necessary as unfavorable intermediate risk is 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 Prolaris prostate cancer assay have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolaris prostate cancer assay.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve additional physical therapy (PT) visits to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve additional PT visits. You say that you would like to stay with this provider that you are established with because their service is great. You also say that you do not want to see the other two providers referred to you by the Plan because one of them have bad services. The Plan denied your request. The Plan says you must use network providers to get medical care and services when there are network providers available.  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. The records provided for review do not show that the services at issue are urgent or emergent. 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 additional physical therapy (PT) visits to be provided by an out-of-network (OON) provider.