Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Partially Favorable

We decided that the Plan has to pre-approve Budesonide. We decided that the Plan does not have to preapprove
a tier exception for Budesonide.
You asked the Plan to pre-approve Budesonide. You say that this is medically necessary. The Plan says that
this drug is not eligible for a tier exception.
We decided that the Plan has to pre-approve Budesonide.
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. Although the Plan has confirmed they have not approved Budesonide, they have
not provided any rationale outside of the tier exception denial. No records to support whether the requested
drug is medically necessary were included in the case file, and the record does not show the Plan made any
effort to obtain them. The Plan denial cannot be substantiated with the documents provided. Therefore, we
decided that the Plan has to pre-approve Budesonide.
We also decided that the Plan does not have to pre-approve a tier exception for Budesonide.
The Plan follows Medicare rules. Medicare rules say that tiered cost-sharing means a process of grouping Part
D drugs into different cost sharing levels.
The requested drug is covered under Medicare Part B, meaning it is not eligible for a tier exception. Tiered
cost-sharing applies only to Part D drugs. Therefore, we decided that the Plan does not have to pre-approve a
tier exception for Budesonide.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on October 3, 2019.
You asked the Plan to waive the copayment for the ambulance transport. You say that this should be waived because it was an emergency transport. The Plan denied your request. The Plan says that there is a $200 copay for each one way ambulance trip.
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 $200 copayment for one way ambulance trips. You have been asked to pay a $200 copayment for the ambulance transport. The ambulance transport falls within the one way ambulance trip benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the ambulance transport provided on October 3, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve routine transportation to a location more than 50 miles from your residence.
You asked the Plan to pre-approve the routine trip exceeding 50 miles. You say that you need to be allowed to have a trip that is over 50 miles. The Plan denied your request. The Plan says there is no exception which allows for coverage of a trip over 50 miles.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers routine transportation when each one-way trip does not exceed 50 miles. Upon investigation, it is found that the requested destination is more than 50 miles from your home. This means that the requested trip is not covered by your plan. Therefore, we decided that the Plan does not have to pre-approve routine transportation to a location more than 50 miles from your residence.
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. The Plan denied your request. The Plan says 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 above. 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 do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that the enrollee's medical status requires the intensity of an IRF stay with close physician or nursing supervision. The enrollee may benefit and participate in additional therapy of physical therapy and occupational therapy, but the enrollee's functional level does not require this on an intensive rehabilitation facility therapy program level 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. 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 surgical extractions (D7210x6) dental extractions (D7140x5) alveoloplasty (D7310) bone replacement graft (D7953) and surgical placement implant (D6010) biologic material to aid in soft tissue regeneration (D4265) bone replacement graft (D7953).
You asked the Plan to pre-approve the extractions and implants. You say that your teeth are infected and is unable to eat. You have 14 teeth that need to be extracted and bone grafts. The Plan denied your request. The Plan says the request for the additional extractions exceeds the plan benefits. Dental implants and related procedures are not covered under the plan 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 surgical extractions (D7210x6) dental extractions (D7140x5) alveoloplasty (D7310) bone replacement graft (D7953) and surgical placement implant (D6010) biologic material to aid in soft tissue regeneration (D4265) bone replacement graft (D7953).
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Trastuzumab (Herceptin) for the enrollee.
You asked the Plan to pre-approve Herceptin. You say that Trastuzumab is an essential part of the enrollee's therapy plan. The Plan denied your request. The Plan says the enrollee has not had a trial or contraindication to Herzuma, Ogivri, Ontruzant, Trazimera, or Kanjinti.
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 Herceptin. Our physician reviewer found that the enrollee has malignant neoplasm of the left breast. The Plan requires a trial of Herzuma, Ogivri, Ontruzant, Trazimera, or Kanjinti before they will approve the requested drug. The documentation does not show that the enrollee has tried and failed the required drugs. The documentation does not support that the required drugs would be less effective, or would likely have adverse effects for the enrollee in this case. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Herceptin have not been met. Therefore, we decided that the Plan does not have to pre-approve Trastuzumab (Herceptin) for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the HCM Next genetic testing for the enrollee.
You asked the Plan to pre-approve the testing. You say that this is medically necessary. The Plan denied your request. The Plan says the entire genetic panel does not medical necessity policy criteria.
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 testing. Our reviewer says that the requested testing is not considered medically reasonable and necessary in this case. Our physician reviewer found while hypertrophic cardiomyopathy is most often caused by mutations in one of several genes, it has not been clearly demonstrated that genetic testing is clinically useful in individual patient management. Testing which has no proven relation to the management of a medical condition for the health of an enrollee is not a covered Medicare benefit. 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 testing have not been met. Therefore, we decided that the Plan does not have to pre-approve the HCM Next genetic testing for the enrollee.
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. The Plan denied your request. The Plan says 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 care is not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee is currently undergoing treatment at an acute care hospital (ACH) after suffering a stroke. His hospital course was complicated by hemorrhagic conversion of the stroke following initiation of anticoagulation. The enrollee was transiently intubated/ventilated but is no longer intubated/ventilated. 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: Testing
Decision: Favorable

We decided that the Plan has to pre-approve Video Head Impulse Testing (VHIT) (92700).
You asked the Plan to pre-approve Video Head Impulse Testing. You say that this was recommended by your
doctor. The Plan denied your request. The Plan says that this procedure has not been proven effective.
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 Video Head Impulse Testing. Our
reviewer says that the requested services are considered medically reasonable and necessary in this case. Our
physician reviewer found the VHIT provides information regarding the function of the semicircular canals and
their afferent pathways. The VHIT is well established as a valid test in both ear-nose-throat and audiology
literature. It is meant to be a diagnostic test and not a treatment for vertigo and dizziness. It also allows for
distinction between peripheral and central vertigo. Given your complaints of long-standing dizziness, any
available vestibular testing can be beneficial in establishing a diagnosis.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Video Head Impulse Testing have been met. Therefore, we decided that the
Plan has to pre-approve Video Head Impulse Testing (VHIT) (92700).
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pay for the services provided to the enrollee on July 9, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that the incorrect place
of service was billed.
The Plan must follow Medicare rules. Medicare rules say that physicians/practitioners who furnish services to a
hospital outpatient, including in a hospital outpatient department (including in a provider-based department of
that hospital) or under arrangement to a hospital shall, at a minimum, report the off campus-outpatient hospital
POS code 19 or on campus-outpatient hospital POS code 22 irrespective of the setting where the patient
actually receives the face-to-face encounter.
We looked at the file and Medicare rules. The documentation provided supports that the enrollee was provided
the services in question as a hospital outpatient. As such, the physician is required to report the outpatient POS
code, as any other POS code would be incorrect. Based on this information, we decided that Medicare rules for
coverage of the services have been met. Therefore, we decided that the Plan has to pay for the services
provided to the enrollee on July 9, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional mileage for routine transportation.You asked the Plan to pre-approveadditional mileage. You say that you need to get to your appointments.The Plandenied your request. The Plan says this exceeds the mileage limit.Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 50 miles per one-way trip. We looked at your request, the records in the case file, and the rules. The requested destination is 55 miles away from your home. Based on this information, we decided that the request exceeds the Plan maximum benefit for coverage of routine transportation.Therefore, we decided that the Plan does not have to pre-approveadditional mileage for routine transportation.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approveOrencia.You asked the Plan to pre-approveOrencia. The Plan denied your request. The Plan says the enrollee has not met the step therapy requirements.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 Orencia. Our reviewer says that Orencia is not medically reasonable and necessary. Our physician reviewer found that the enrollee has not trialed Remicade, Inflectra, or Simponi Aria. Step therapy, as outlined by the plan, requires these be trialed first. The documentation does not outline contraindications or reasons this medication was not considered. Without the support of the documentation, Orencia is not necessary, as step criteria is not 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 Orencia have not been met.Therefore, we decided that the Plan does not have to pre-approveOrencia.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan has to pre-approve Gammagard Liquid (J1569).

You asked the Plan to pre-approve Gammagard Liquid (J1569). You say that the requested Gammagard Liquid (J1569) is medically necessary. The Plan denied your request. The Plan says that the requested Gammagard Liquid (J1569) is not medically necessary.

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. Specifically, it is the plan's responsibility to show that its decision to deny coverage is correct. Records from a plan provider are considered to be within the control of the plan. In cases where the plan has not supplied records from a plan provider that are critical to its decision, we may properly find that the denial is not medically appropriate or justifiable. Enrollees should not be penalized for a plan's failure to obtain records that are within the plan's control. Therefore, we decided that the Plan has to pre-approve Gammagard Liquid (J1569).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveIV lidocaine infusion treatments.You asked the Plan to pre-approvethese services. The Plan denied your request. The Plan says that peer review literature suggests that further studies were recommended with larger sample sizes to assess the benefit of IV lidocaine infusion treatments for fibromyalgia.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 these services. Our reviewer says that these services are not medically reasonable and necessary in this case. Intravenous lidocaine infusion is being requested for the treatment of fibromyalgia. Submitted documentation, Medicare guidelines, and Medicare approved compendia were considered. Review of the compendia and peer literature does not support the use of intravenous lidocaine for the treatment of fibromyalgia symptoms. Literature recommends additional studies. Our physician reviewer found that your condition does not meet Medicare criteria for coverage of IV lidocaine infusion treatments.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pre-approveIV lidocaine infusion treatments.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for a visual field examination (CPT 92083) provided October 21, 2019.You asked the Plan to pay for the visual field examination. You say that this was your first eye exam in 2019 and this test was for cataracts and should be covered. The Plan denied your request. The Plan says the Plan covers one routine eye exam every year.Medicare generally does not cover routine vision services. However, the Plan offers a routine vision benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.We looked at the file and the Plan's rules. The file shows that a visual field examination is not part of the Plan's routine eye exam benefit. Therefore, we decided that the Plan does not have to pay for a visual field examination(CPT 92083) provided on October 21, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea Freestyle Libre for the enrollee.You asked the Plan to pre-approvethe requested device. The Plan denied your request. The Plan says coverage criteria has not been met.The Plan follows Medicare rules. Medicare rules say that glucose monitors are only covered under certain medical indications. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Planwas correct in denying the request to pre-approve the requesteddevice. Our physician reviewer found that the enrollee with type 2 diabetes is on Levemir. The enrollee takes 30 units in the morning, and 18 units in the evening. There is no log given. There areno adjustmentsin doses on a daily basis based on the blood glucoselevel. There is no A1c givento indicate overall control. Itis also not clear what the blood glucosedata is going to provide for the enrollee and/or physician. We are not told if the enrollee is at goal or not,so the utility of thedata is unclear. Therefore, the requested device is not medically reasonable and necessary.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided thatMedicare rules for coverage of the requesteddevice have not been met.Therefore, we decided that the Plan does not have to pre-approvea Freestyle Libre for the enrollee.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Gammagard Liquid (J1569).

You asked the Plan to pre-approve Gammagard Liquid (J1569). You say that the requested Gammagard Liquid (J1569) is medically necessary. The Plan denied your request. The Plan says that the requested Gammagard Liquid (J1569) is not medically necessary.

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. Specifically, it is the plan's responsibility to show that its decision to deny coverage is correct. Records from a plan provider are considered to be within the control of the plan. In cases where the plan has not supplied records from a plan provider that are critical to its decision, we may properly find that the denial is not medically appropriate or justifiable. Enrollees should not be penalized for a plan's failure to obtain records that are within the plan's control. Therefore, we decided that the Plan has to pre-approve Gammagard Liquid (J1569).