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

We decided that the Plan does not have to pre-approve insertion of stabilization/distraction device.
You asked the Plan to pre-approve insertion of stabilization/distraction device. 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 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 insertion of stabilization/distraction device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has lumbar spinal stenosis. Interspinous distraction devices remain experimental. More research is needed to show safety and efficacy. 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 insertion of stabilization/distraction device have not been met. Therefore, we decided that the Plan does not have to pre-approve insertion of stabilization/distraction device.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve wireless capsule endoscopy, gastrointestinal tract imaging, intraluminal (e.g., capsule endoscopy), esophagus through ileum, with interpretation and report (91110).
You asked the Plan to pre-approve wireless capsule endoscopy. You say that you are requesting a standard appeal and have provided supporting clinical documentation. The Plan denied your request. The Plan says the request is not medically necessary because the records show the enrollee has not had recent upper and lower endoscopic testing.
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 wireless capsule endoscopy. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found per the LCD, covered indications for wireless capsule endoscopy require, in evaluation of the enrollee's anemia, that she has undergone upper and lower GI endoscopies within the past 12 months (esophagogastroduodenoscopy (EGD) and colonoscopy) that have failed to identify a bleeding source and her small bowel biopsy proved negative for active celiac disease. These requirements are not met in enrollee's case. In addition, available records do not support that the appellant's celiac disease is symptomatic despite treatment nor is there suspected or confirmed GI obstruction, stricture, or fistulae. The available records offer multiple etiologies for her anemia, without clinical evidence presented that warrant undue concern for GI hemorrhage as etiologic. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of wireless capsule endoscopy have not been met. Therefore, we decided that the Plan does not have to pre-approve wireless capsule endoscopy, gastrointestinal tract imaging, intraluminal (e.g., capsule endoscopy), esophagus through ileum, with interpretation and report (91110).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional days of your inpatient psychiatric admission from July 29, 2021, forward.
You asked the Plan to pre-approve inpatient psychiatric admission. You say that the services are necessary. The Plan denied your request. The Plan says the requested admission is not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment.
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 inpatient psychiatric admission. Our reviewer says that the inpatient psychiatric admission is not medically necessary. Our physician reviewer found the provided documentation shows that it was not expected you would improve in a reasonable period of time beyond the dates in question as you were not showing any dangerousness to self or others, auditory or visual hallucinations and without aggressive behaviors while not showing any acute threats of safety. The reviewer also found that the records provided, you do not meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in question of July 29, 2021, forward and could have been treated in a lesser restrictive 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 inpatient psychiatric admission have not been met. Specifically, the file does not show that you were showing any dangerousness to self or others, auditory or visual hallucinations and without aggressive behaviors while not showing any acute threats of safety. Therefore, we decided that the Plan does not have to pre-approve additional days of your inpatient psychiatric admission from July 29, 2021, forward.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc (J7325).

You asked the Plan to pre-approve Synvisc. You say that this drug is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage 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 looked at the file and Medicare rules. In this case, medical records were not provided to indicate that the step therapy drugs have been trialed and/or would not be appropriate for the patient's condition. Based on this information, we decided that Medicare rules for coverage of Synvisc have not been met. Therefore, we decided that the Plan does not have to pre-approve Synvisc (J7325).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the crown (D2740), core buildup (D2950), surgical procedure for isolation of tooth with rubber dam (D3910) and canal preparation (D3950).
You asked the Plan to pre-approve the crown (D2740), core buildup (D2950), surgical procedure for isolation of tooth with rubber dam (D3910) and canal preparation (D3950). 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 crown (D2740), core buildup (D2950), surgical procedure for isolation of tooth with rubber dam (D3910) and canal preparation (D3950).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot insert orthotics.
You asked the Plan to pre-approve foot orthotics. You say that the services are an approved item. The Plan denied your request. The Plan says the services are not covered.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot insert orthotics
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve out of network providers.
You asked the Plan to pre-approve out of network providers. You say that you prefer to see the requested provider. The Plan denied your request. The Plan says this provider is not in network.
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 provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve out of network providers
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Reclast.
You asked the Plan to pre-approve Reclast. You say that this is medically necessary. The Plan denied your request. The Plan says this is not supported for the enrollee's condition.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Reclast. Our reviewer says that the requested use of Reclast is not supported. Our physician reviewer found the record indicates that the enrollee has a diagnosis of hypercalcemia. Although the record also indicates that the enrollee has osteopenia with a high risk of fracture, no bone density report is provided. Neither the Food and Drug Administration nor the Medicare-approved drug compendia support this drug for the enrollee's condition. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Reclast have not been met. Therefore, we decided that the Plan does not have to pre-approve Reclast.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that you wanted to go to a skilled nursing facility. You also say that your provider is trying to get you into the IRF first. The Plan denied your request. The Plan says the IRF admission is not medically necessary.
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. The
enrollee is stable and does not have complex nursing or rehabilitation needs. The reviewer found that the
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational
therapy, and an intensive rehabilitation therapy program. The reviewer found there is no documentation of a
need for an intensive rehabilitation program. The reviewer also found that there is not a reasonable expectation
that the 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. Specifically, there is no documentation of a need
for an intensive rehabilitation program. Therefore, we decided that the Plan does not have to pre-approve acute
inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the crown (D2740) and core buildup (D2950) for tooth #6 and #11.
You asked the Plan to pre-approve the crown (D2740) and core buildup (D2950). You say that you had multiple fillings done and the doctor cannot do a root canal. You say that they are holding in your partial dentures and the teeth need crowns to protect it from further decay. The Plan denied your request. The Plan says the x-rays do not show severe destruction negating the medical necessity of the services.
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 crown (D2740) and core buildup (D2950) 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 crown (D2740) and core buildup (D2950). Our physician reviewer found that there is insufficient damaged structure to qualify for crowns due to the lack of incisal involvement. Our reviewer says that core buildups are only required when there is insufficient structure to retain a crown. Our reviewer says that the teeth appear to be restorable with conventional materials and do not require full coverage crowns
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 crown (D2740) and core buildup (D2950) have not been met. Therefore, we decided that the Plan does not have to pre-approve the crown (D2740) and core buildup (D2950) for tooth #6 and #11.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve an internal loop recorder.
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 that the services are not 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 these services. Our reviewer says that the services are medically necessary. Our physician reviewer found the enrollee has several risk factors for atrial fibrillation, including hypertension, diabetes and mild left ventricular dysfunction by echo. However, her only documented episode of paroxysmal atrial fibrillation was in the setting of acute respiratory failure secondary to Coronavirus pneumonia. She has had no symptomatic recurrences since that time. Her CHA2DS@VASc score is elevated and if she had a significant burden of recurrent atrial fibrillation, she would require long-term anti-coagulation. As there is a plan to discontinue the anti-coagulation in the absence of recurrent paroxysmal atrial fibrillation (in this case, occurring outside the acute illness situation) prolonged monitoring for asymptomatic recurrence is necessary. The services are therefore reasonable and medically necessary 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 these services have been met. Therefore, we decided that the Plan has to pre-approve an internal loop recorder.
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 pneumatic compression device (E0652) and segmental pneumatic appliance (E0667).
You asked the Plan to pre-approve a pneumatic compression device and appliance. You say that please see attached for documentation from the enrollee's healthcare team in support of medical necessity of the prescribed Flexitouch PCD for the treatment of his lymphedema. The Plan denied your request. The Plan says the enrollee does not meet the LCD criteria for an advanced lymphedema pump as there is no failed four week trial of a basic pneumatic compression device of either E0650 or E0651.
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) and segmental pneumatic appliance (E0667).
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 admission to an LTACH is medically necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically necessary.
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 based on the documentation provided the enrollee appears to be not stable enough for transfer at this time, and only requires short-term additional acute care services that can safely be administered at the current facility. The enrollee does not require services at the LTACH that are not already available 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.
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 the upper and lower partial denture (D5225 and D5226).
You asked the Plan to pre-approve the upper and lower partial denture (D5225 and D5226). You say that you have a lot of missing teeth and you need a resolution. 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 upper and lower partial denture (D5225 and D5226).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of Adcetris and Ruxience.
You asked the Plan to pre-approve Adcetris and Ruxience. You say that this regimen is a feasible and active frontline regimen for the enrollee's condition. The Plan denied your request. The Plan says the denial of authorization for these drugs is correct, because this regimen is not being requested for a medically-accepted indication.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Adcetris and Ruxience. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested use of Adcetris and Ruxience. Our physician reviewer found Adcetris and Ruxience are not Food & Drug Administration (FDA) approved for the enrollee's diagnosis. The requested use is not supported by one of the major drug compendia or by clinical research appearing in a Medicare-approved medical journal.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Adcetris and Ruxience have not been met. Therefore, we decided that the Plan does not have to pre-approve use of Adcetris and Ruxience.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hearing aids.
You asked the Plan to pre-approve hearing aids. You say that you were informed your doctor that if you continue to not use your hearing aid this may affect your health by accelerating Alzheimer. The Plan denied your request. The Plan says the member has exhausted the benefit as the member already received a hearing aid on June 17, 2020. Therefore, the member's benefit for hearing aid has been exhausted.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only every two (2) years. We looked at the file and the Plan's rules. The file shows that you used the hearing aid benefit on
June 17, 2020, and you are not eligible for coverage until 2022. Therefore, we decided that the Plan does not have to pre-approve hearing aids