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

We decided that the Plan does not have to pre-approve Hyalgan supartz injections.
You asked the Plan to pre-approve Hyalgan supartz injections. You say that the requested Hyalgan supartz
injections are medically necessary. The Plan denied your request. The Plan says the requested Hyalgan supartz
injections are not medically necessary.
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 Hyalgan supartz injections. Our
reviewer says that the requested Hyalgan supartz injections are not medically necessary. Our physician
reviewer found the enrollee was being treated for bilateral knee osteoarthritis. She presented with bilateral knee
pain. She reports that the knee has been painful for several months to years. It has been a gradual increase. The
pain is worst in the medial aspect of the knee but hurts throughout when it is swollen. It feels like a dull ache
with sharp pains at times. It is worse with activity. Exam reveals bilateral knee pain with palpation of the
medial joint line. Range of motion is 0-130. There is 1+ knee effusion. However, detailed documentation is not
evident regarding trial and failure of recent, reasonable and comprehensive less invasive conservative care
measures. She had received bilateral knee corticosteroid injections on October 13, 2021, and January 26, 2022,
without clear documentation of benefit from those injections. However, there is no documentation of any trial
and failure of physical therapy for the bilateral knees. Additionally, x-rays are noted on October 13, 2021,
exam; however, formal imaging studies were not provided for review to corroborate bilateral knee
osteoarthritis.
There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity
of this request as an exception. Therefore, the request for Hyalgan Supartz injections is not medically
reasonable or necessary and the documentation does not support that the Hyalgan Supartz injections is safe and
effective 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 Hyalgan supartz injections have not been met. Therefore, we decided that the
Plan does not have to pre-approve Hyalgan supartz injections.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health physical therapy visits for the enrollee.
You asked the Plan to pre-approve the visits. You say that this is medically necessary. The Plan denied your
request. The Plan says the records do not support the need for a skilled physical therapist to make more visits at
this time.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for
home health care services.
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 visits. Our reviewer says that the
requested services are not medically reasonable or necessary. Our physician reviewer found that in this case,
the documentation doesn't support that the enrollee requires additional skilled rehab services to provide
treatment that is medically necessary. The enrollee does not require additional skilled rehab services to
effectively provide treatment, care, and/or services in order to improve the member's condition, perform a
maintenance program to maintain the enrollee's condition and/or prevent deterioration. The enrollee has been
medically stable without any recent exacerbations of chronic medical problems or hospitalizations. The
requested home health services are not medically necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the visits have not been met. Therefore, we decided that the Plan does not have
to pre-approve home health physical therapy visits for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve testosterone cypionate for the enrollee.
You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your request. The Plan says that this drug is not covered under the medical benefit.
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 for the enrollee.
Benefits for this drug 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve MyoPro orthotic device.
You asked the Plan to pre-approve a MyoPro orthotic device. You say that the requested device is supported as appropriate intervention and is reasonably and medically necessary as recognized by medical communities and key opinion leaders in rehabilitation. The Plan denied your request. The Plan says medical studies have not proven that the device is helpful for treatment of the enrollee's health problem.
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 a MyoPro orthotic device. Our reviewer says that a MyoPro orthotic device is not considered medically reasonable and necessary in this case. Our physician reviewer found no documentation from the enrollee's treating providers was included in the available records which recommended the device and describing other therapies tried and failed. There is no evidence that the MyoPro orthotic device is the optimal treatment option for the enrollee's condition. In addition, current clinical guidelines designate robotic therapy to be of "uncertain utility compared with dose-matched conventional upper limb exercise therapies" with unproven benefit in the home environment.
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 MyoPro orthotic device have not been met. Therefore, we decided that the Plan does not have to pre-approve MyoPro orthotic device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve crowns - porcelain fused to noble metal (D2752) for
teeth #2, #12, and #13 and core buildup, including any pins when required (D2950) for teeth #12 and #13.
You asked the Plan to pre-approve the crown and core buildup. You say that new buildup and crowns are
needed to restore tooth anatomy and protect tooth due to placement of restoration. The Plan denied your
request. The Plan says there is no evidence of decay or missing crown to support the need for replacement.
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 and
core buildup 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 and core buildup. Our
reviewer says that crowns - porcelain fused to noble metal (D2752) for teeth #2, #12, and #13 and core buildup,
including any pins when required (D2950) for teeth #12 and #13 are not medically necessary. Our physician
reviewer found that Tooth #2 presents with an existing occlusal restoration and mesial decay. The tooth has
intact cusps and will have about 35% structural compromise after restoration of the mesial decay. The tooth
would not require a full coverage crown. Tooth #12 had endodontic access cut in it, and otherwise has what
appears to be intact margins. The existing crown would be repairable with an occlusal restoration and would
not require replacement. A core buildup would not be necessary in this situation. Tooth #13 also had
endodontic access; however, the endodontic fill is several millimeters long and beyond the apex of the root,
making the root canal fill unacceptable with a poorer long-term prognosis. A replacement crown would not be
indicated with an inadequate root canal fill. Also, the crown appears intact aside from the endodontic access
and some occlusal fracture of porcelain and is functional. The root canal fill must be corrected and then the
tooth can be sealed with a restoration and possibly a post support given the radiographic appearance. Currently
none of the requested services are considered necessary.
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 and core buildup have not been met. Therefore, we decided that the
Plan does not have to pre-approve crowns - porcelain fused to noble metal (D2752) for teeth #2, #12, and #13
and core buildup, including any pins when required (D2950) for teeth #12 and #13.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve computed tomography angiography (CTA) of the abdomen/pelvis.
You asked the Plan to pre-approve CTA scan. You say that the enrollee is in need of this scan. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because the Plan approved a CTA of the chest, but the results have not been received to show why this test is needed.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 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 CTA scan. Our reviewer says that the enrollee does not meet the Medicare criteria for a CTA scan. Our physician reviewer found the Plan has authorized a CT angiogram of the chest. The enrollee had a CT scan of the chest previously that incidentally showed ectasia of the ascending aorta. The enrollee had additional imaging including an ultrasound that showed a normal abdominal aorta. More recent follow-up imaging of the chest, abdomen, and pelvis was ordered. The documentation does not indicate that the enrollee is having any symptoms or alternative imaging that would necessitate a CTA of the abdomen or pelvis. This is not medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CTA scan have not been met. Therefore, we decided that the Plan does not have to pre-approve computed tomography angiography (CTA) of the abdomen/pelvis
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional home health services (G0151, G0299).
You asked the Plan to pre-approve the additional home health services. You say that ongoing home health services are medically necessary. The Plan denied your request. The Plan says the enrollee's needs can be met at a lower level of care.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 additional home health services. Our reviewer says that additional home health services are not medically necessary. Our physician reviewer found the enrollee has no further skilled therapy or nursing needs. 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 additional home health services have not been met. Therefore, we decided that the Plan does not have to pre-approve additional home health services (G0151, G0299).
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ab-externo XEN gel stent implantation.
You asked the Plan to pre-approve Ab-externo XEN gel stent implantation. You say that the requested Ab-
externo XEN gel stent implantation is medically necessary. The Plan denied your request. The Plan says the
enrollee does not meet criteria for the requested Ab-externo XEN gel stent implantation.
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 Ab-externo XEN gel stent implantation.
Our reviewer says that the enrollee does not meet criteria for the requested Ab-externo XEN gel stent
implantation. Our physician reviewer found the enrollee is with diagnoses of Primary open-angle glaucoma of
the right eye moderate stage, and Primary open-angle glaucoma of the left eye severe stage.
The enrollee also has bilateral age-related cataracts. The enrollee is taking three eye drops:
Dorzolamide/Tomolol, Vyzulta, and Rhopressa. On December 13, 2021, the enrollee's intraocular pressure
(IOP) was 12 in the right eye and the left eye. The IOP was improved and was within the target range. LCD
L37244 states "NGS considers one iStent, iStent inject, or Hydrus device per eye medically reasonable and
necessary for the treatment of adults with mild or moderate open-angle glaucoma and a cataract when the
individual is currently being treated with an ocular hypotensive medication and the procedure is being
performed in conjunction with cataract surgery. One XEN45 device per eye is covered for the management of
refractory glaucoma, defined as prior failure of filtering/cilioablative procedure and/or uncontrolled IOP
(progressive damage and mean diurnal medicated IOP greater than or equal to 20 mm Hg) on maximally
tolerated medical therapy (i.e., greater than or equal to 4 classes of topical IOP-lowering medications, or fewer
in the case of tolerability or efficacy issues).
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Ab-externo XEN gel stent implantation have not been met. Therefore, we
decided that the Plan does not have to pre-approve Ab-externo XEN gel stent implantation.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a root canal to be performed by an Oral Surgeon.
You asked the Plan to pre-approve a root canal to be performed by an Oral Surgeon. You say that you would
like the Plan to reconsider their denial. The Plan denied your request. The Plan says supplemental dental
services are only covered by a participating general dentist.
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 when provided by an Oral Surgeon. Therefore, we decided that the Plan
does not have to pre-approve a root canal to be performed by an Oral Surgeon.
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 that the enrollee continues to receive acute care services, and these have not been denied. The medical record does not indicate that the enrollee requires services that she is not currently receiving but that would be available at the LTACH 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 pay for the periodontal procedures (D4999) or pay more for the
periodontal scalings and root planings (D4341) provided on March 8, 2021.
You asked the Plan to pay for the periodontal procedures and to pay more for the scalings and planings. You
say that this was a simple cleaning done by a Plan assigned dentist. You also say that the enrollee was charged
$1,200.00 when they should only have had a $10.00 copay and no out-of-pocket expenses. The Plan denied
your request. The Plan says the allowed amount for the scalings and planings were covered. The Plan also says
that the periodontal procedures 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 unspecified periodontal procedures
(D4999) are not among those covered under this benefit. The Plan contract also says that the enrollee is
responsible for a $125 copayment for each periodontal scaling and root planing (D4341). Therefore, we
decided that the Plan does not have to pay for the periodontal procedures (D4999) or pay more for the
periodontal scalings and root planings (D4341) provided on March 8, 2021.
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 LTACH admission is
medically necessary. The Plan denied your request. The Plan says the requested LTACH admission 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 admission is not medically necessary. Our physician reviewer found based on the
documentation provided, the enrollee is currently undergoing treatment at an acute care hospital (ACH) for
complications following a cardiac procedure. The enrollee is not intubated/ventilated. There is no evidence that
the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide
the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can
remain at the current ACH until such time no acute services are required. The enrollee can then be
transferred/discharged to a lower level of care for any ongoing long term care needs.
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: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the implantation of spinal neurostimulator electrodes.
You asked the Plan to pre-approve the implantation of spinal neurostimulator electrodes. You say that you have
done all of the tests, injections, physical therapy and medications. You say that nothing is happening. The Plan
denied your request. The Plan says the requested procedure is not medically necessary. The Plan says that there
is no documentation of recent physical therapy or a psychological evaluation.
The Plan follows Medicare rules. Medicare rules say that the implantation of dorsal column or depth brain
stimulators or services and supplies related to such implantation are only covered when specific conditions
have been met.
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 implantation of spinal
neurostimulator electrodes. Our reviewer says that the criteria for coverage have not been met. Our physician
reviewer found there is no psychiatric evaluation in the medical 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 implantation of spinal neurostimulator electrodes have not been met.
Therefore, we decided that the Plan does not have to pre-approve the implantation of spinal neurostimulator
electrodes.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist office visit provided on February 8, 2021.
You asked the Plan to waive the copayment for the specialist office visit. You say that the services should be covered as you did not have an office visit. The Plan denied your request. The Plan says the cost-sharing applied correctly because you had surgical services done in a specialist's office.
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 $50 copayment for Physician/Practitioner services, including doctor's office visits.
You have been asked to pay a $50 copayment for the specialist office visit. 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. Therefore, we decided that the Plan does not have to waive the copayment for a specialist office visit provided on February 8, 2021.