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

 
We decided that the Plan does not have to pre-approve hearing aids through Byron Hudson Valley Hearing Aid 
Centers. 
 
You asked the Plan to pre-approve hearing aids through Byron Hudson Valley Hearing Aid Centers. You say 
that the closest in-network facility is 45 miles away and would be inconvenient to get to. The Plan denied your 
request. The Plan says hearing aids that are not provided through a TruHearing provider are not covered. 
 
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 plans coverage rules apply in this case. The Plan pays for 
hearing aids only when they are TruHearing-branded.  
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of hearing aids through Byron Hudson Valley Hearing Aid Centers have not been met. Therefore, we 
decided that the Plan does not have to pre-approve hearing aids through Byron Hudson Valley Hearing Aid 
Centers.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro powered arm brace (L8702).  
 
You asked the Plan to pre-approve the arm brace. You say that the requested arm brace is medically necessary 
for the enrollee. The Plan denied your request. The Plan says experimental items and items that are not shown 
to be safe and effective cannot be 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 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 arm brace. Our reviewer says that 
the requested arm brace is not considered medically reasonable and necessary in this case. Our physician 
reviewer found the MyoPro arm brace is not known to be effective, based on scientific evidence, professional 
standards and expert opinion, in improving health outcomes. The reviewer found that the requested arm brace 
is not the standard of care for your condition or in widespread use for your condition based on scientific evidence. There is insufficient evidence in the literature that the MyoPro arm brace will improve the long-term 
outcomes for you. There is insufficient evidence in the literature that this device will increase participation in 
two-handed activities. Therefore, the reviewer found that the requested arm brace 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 arm brace have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a MyoPro powered arm brace (L8702).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve CGM and supplies. 
 
You asked the Plan to pre-approve a therapeutic CGM and supplies. You say that the request is medically 
necessary for the enrollee. The Plan denied your request. The Plan says the therapeutic CGM and supplies are 
not medically necessary for the enrollee. 
 
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 a therapeutic CGM and supplies. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found the record indicates 
that the enrollee has diabetes; however, the record provided does not indicate that the enrollee is being treated 
with insulin or has problematic hypoglycemia as defined by the Medicare rules. The elements of the coverage 
criteria are not satisfied. 
  
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 therapeutic CGM and supplies have not been met. Therefore, we decided that 
the Plan does not have to pre-approve CGM and supplies.
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 you are not able to walk and are having difficulty 
receiving physical therapy at home. The Plan denied your request. The Plan says ongoing skilled care can be 
provided in an alternative setting on an intermittent basis.  
 
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 the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do have daily skilled therapy needs that require 
the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require daily 
skilled nursing and skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Freestyle Libre 3 Kit. 
 
You asked the Plan to pre-approve Freestyle Libre 3 Kit. You say that the Freestyle Libre 3 Kit is necessary for 
the enrollee. The Plan denied your request. The Plan says the Freestyle Libre 3 sensor cannot be covered by 
Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that a non-adjunctive continuous glucose monitor 
(CGM) must be billed with code E2103. The rules also say that only devices reviewed by the PDAC and 
assigned code E2103 may be billed using this code.  We looked at the file and Medicare rules. The request at issue is for the Freestyle Libre 3 non-adjunctive CGM. 
However, this device has not been reviewed by the PDAC and has not been assigned code E2103. As such, this 
non-adjunctive CGM device is not eligible for coverage at this time. Therefore, we decided that the Plan does 
not have to pre-approve Freestyle Libre 3 Kit.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve  a Group 3 power wheelchair with power tilt and 
recline, and accessories. 
 
You asked the Plan to pre-approve a Group 3 power wheelchair with multiple power options. You say that the 
enrollee needs the requested power wheelchair. The Plan denied your request. The Plan says the notes do not 
show that the enrollee has a medical need for power tilt and recline.  
 
The Plan follows Medicare rules. Medicare rules say that a Group 3 power wheelchair with tilt and recline may 
be covered when certain criteria 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 a Group 3 power wheelchair with 
multiple power options. Our reviewer says that the requested Group 3 power wheelchair with power tilt and 
recline is not medically necessary. Our physician reviewer found the provided documentation indicates the 
enrollee can ambulate short distances with crutches but is functionally non-ambulatory and cannot use a cane 
or walker for functional mobility. The documentation indicates the enrollee cannot functionally propel a 
manual wheelchair due to upper extremity weakness and a lack of endurance. The enrollee cannot operate a 
power scooter due to impaired sitting balance. The enrollees current power wheelchair is 6 years in age and 
requires replacement. The reviewer found that the enrollee requires a power wheelchair for mobility and 
accomplishing daily activities. However, the clinical documentation is insufficient why a lower-level power 
wheelchair would not suffice for the enrollees needs versus a Group 3 power wheelchair. There is inadequate 
clinical documentation regarding why the enrollee requires power tilt and recline and cannot perform pressure 
relief. The documentation indicates the enrollee has intact sensation, has no history of skin breakdown, and 
only requires supervision for transfers. The documentation also indicates that the enrollee is at low risk for skin 
breakdown. Therefore, the reviewer found that the requested Group 3 power wheelchair with power tilt and 
recline 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 a Group 3 power wheelchair with multiple power options have not been met. 
Therefore, we decided that the Plan does not have to pre-approve  a Group 3 power wheelchair with power tilt 
and recline, and accessories.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on SNF criteria. 
 
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 the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the clinical documentation does not show that the enrollee requires daily skilled 
services on an inpatient basis in a skilled nursing facility, thus 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 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6549. 
 
You asked the Plan to pre-approve the compression stockings. The Plan denied your request. The Plan says 
elastic stockings are not durable medical equipment. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are 
noncovered because they do not meet the statutory definition of a surgical dressing.   
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6549.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda. 
 
You asked the Plan to pre-approve Keytruda. You say that the enrollee really wants this medication for their 
treatment. The Plan denied your request. The Plan says the requested drug is not medically necessary. 
 
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 Keytruda. Our reviewer says that 
Keytruda is not medically necessary. Our physician reviewer found the requested use of Keytruda is not Food 
and Drug Administration (FDA) approved for the enrollees diagnosis. The reviewer found that the use 
supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. Therefore, the reviewer found that the requested use of Keytruda 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 Keytruda have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve crowns (D2740) for tooth #'s 6 and 25. 
 
You asked the Plan to pre-approve the crowns. You say that the crowns you receive in February 2023 never fit 
properly, and you are in pain. The Plan denied your request. The Plan says your benefit for the requested item 
or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service February 28, 2023. 
Therefore, we decided that the Plan does not have to pre-approve crowns (D2740) for tooth #'s 6 and 25.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a therapeutic CGM system. 
 
You asked the Plan to pre-approve a therapeutic CGM system. You say that a therapeutic CGM system is 
necessary for the enrollee. The Plan denied your request. The Plan says that this benefit limitation has been 
exhausted. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not include proof the benefit limitation has been exhausted. 
Therefore, we decided that the Plan has to pre-approve a therapeutic CGM system.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the second opinion to be provided by an out-of-network 
provider (OON). 
 
You asked the Plan to pre-approve the out-of-network services. You say that you need a second opinion from 
the requested OON provider. You state that Boston has treatment options and trails that are not available in 
Maine. You state that you not being able to pursue treatment with this OON provider could jeopardize your 
health and overall outcomes.  The Plan denied your request. The Plan says there is no evidence that the enrollee 
cannot receive the care needed within the coverage area.  
 
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 at issue in this case is not a network provider with the Plan. 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 out-of-network services. Our physician reviewer found the Plans denial 
is medically justified on the basis that it is offering adequate care to meet your medical needs through referral 
to in-network providers. There is not anything unique about your condition that that would make it medically 
necessary for you to see the requested out-of-network provider. The Plan has shown that they have in-network 
providers who meet the Standards of Care required for treatment of your condition. Therefore, this condition 
can be treated by in-network provider. 
 
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 out-of-network services have not been met.  
 
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 the out-of-network services. Therefore, we decided 
that the Plan does not have to pre-approve the second opinion to be provided by an out-of-network provider 
(OON).
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 an LTACH admission is medically 
necessary. The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient acute 
care and is currently unstable for transfer to an LTACH. 
 
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 record indicates that the enrollee has ongoing acute medical issues and still 
requires acute care services. 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 they are not currently 
receiving but that would be available at the LTACH facility. The requested service cannot be recommended as 
the elements of the coverage rules are not satisfied. 
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that the current facility is not equipped to care for the 
enrollee's required medical needs. The Plan denied your request. The Plan says the enrollee does not meet the 
criteria for a 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found clinical documentation does no show that the enrollee requires daily skilled services 
on an inpatient basis in a skilled nursing facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee requires intensive rehabilitation with 
daily physician management, rehab nursing and intensive therapies to restore their functional status. The Plan 
denied your request. The Plan says they did not receive records showing the level of care the enrollee needs.  
 
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 is medially stable. There are no documented rehab skilled nursing needs 
identified. The enrollee's rehab needs can be provided in an alternate and low intensity setting such as in-home 
with 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 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Euflexxa (J7323). 
 
You asked the Plan to pre-approve the medication. You say that the medication is medically necessary. The 
Plan denied your request. The Plan says the requested drug does not meet step therapy criteria.   
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the medication. Our physician reviewer 
found the provider requested Euflexxa fo the treatment of osteoarthritis. The enrollee has not trialed one 
viscosupplemental treatment such as Monovisc, Orthovisc, Synvisc, or Synvisc-One. Step therapy, as outlined 
by the Plan, requires that one of these be trialed first. The documentation does not outline contraindications or 
reasons these medications were not considered. Without the support of the documentation, Euflexxa is not 
approved as step criteria have not been met. 
 
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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Euflexxa (J7323).