Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve facet joint injections.

You asked the Plan to pre-approve facet joint injections (64490, 64491,64492). You say that you need the
injections. The Plan denied your request. The Plan says that the clinical documentation provided does not
support the medical necessity for the facet joint injections.

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 facet joint injections (64490,
64491,64492). Our reviewer says that the requested items/services are considered medically reasonable and
necessary in this case. Our physician reviewer found the request meets the criteria of the LCD. The patient has
had an x-ray and has been doing home physical therapy. The request is medically reasonable and 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 facet joint injections (64490, 64491,64492) have been met. Therefore, we
decided that the Plan has to pre-approve facet joint injections.

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: 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 enrollee would benefit from care in the LTACH setting. The Plan denied your request. The Plan says the enrollee's needs are met in the current facility.

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 enrollee was admitted on 2/25/2021 due to respiratory failure caused by COVID-19. She was intubated on 2/28/21 and tracheostomy was placed 3/12. It is documented that she is unresponsive (even without sedation) with poor prognosis. 

There is no documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. 

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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics for the enrollee.

You asked the Plan to pre-approve foot orthotics. You say that these are medically necessary. The Plan denied your request. The Plan says this item is not a covered benefit.

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 the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of orthotics for the enrollee's condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics for the enrollee.
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 for the enrollee.

You asked the Plan to pre-approve IRF care. You say that IRF admission is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met.

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 based on the documentation provided, the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at a lower level of care. Medicare coverage criteria are 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 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 for the enrollee.
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 for the enrollee.

You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met.

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 based on the documentation provided, the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at a lower level of care. 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 for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a semi-precision attachment abutment, tooth 19 and 30 (D6052) for the enrollee.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered benefit.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a semi-precision attachment abutment, tooth 19 and 30 (D6052) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve orthopedic shoes.

You asked the Plan to pre-approve orthopedic shoes (L3216, L3649). You say that you need the orthopedic
shoes for pain relief. The Plan denied your request. The Plan says these items are not a covered benefit.

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 orthopedic shoes.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve partial upper and lower dentures.

You asked the Plan to pre-approve dentures. You say that you need these dentures to be able to eat. The Plan denied your request. The Plan says the denial of authorization for these dentures is correct, because you previously received dentures, which was less than 60 months ago.

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 1 set of dentures every 5 years.

You previously received a set of dentures, which was less than 5 years ago. Therefore, the benefit for dentures is currently exhausted. Therefore, we decided that the Plan does not have to pre-approve partial upper and lower dentures.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a CT scan of the abdomen/pelvis.

You asked the Plan to pre-approve a CT scan. You say that the requested CT scan is medically necessary. The
Plan denied your request. The Plan says that the requested CT scan 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. The plan did not provide sufficient medical records
in order to determine if the enrollee meets Medicare criteria for the requested CT scan. The case file the Plan
sent was largely incomplete. After multiple attempts, the Plan has not responded to our requests. Therefore, we
decided that the Plan has to pre-approve a CT scan of the abdomen/pelvis.

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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia (denosumab), 1MG injection (CPT code J0897), for the enrollee.

You asked the Plan to pre-approve the medication. You say that this would be used to treat the enrollee's Osteoporosis. You state the enrollee's bone density is continually decreasing and they do not tolerate bisphosphonate's given their history of reflux. The Plan denied your request. The Plan says the documentation does not show that the enrollee has osteoporosis or has failed or are intolerant of other available osteoporotic therapy. The Plan states the records do not show that the enrollee's oral health has been discussed or that they have been instructed to take specific amounts of calcium and vitamin D daily. 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 based on the medical records provided the documentation does not meet all of the requirements listed in the LCD: L33270 for Medicare coverage. Records do not clearly document that the enrollee was instructed to take 1,000 mg of calcium per day. Records do not document a diagnosis of osteoporosis is met with high risk for fracture or that the enrollee has failed or is intolerant of other available osteoporotic therapy. 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 Prolia (denosumab), 1MG injection (CPT code J0897), 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. You say that the enrollee would benefit from care in an LTACH. The Plan denied your request. The Plan says the enrollee's needs are being met in the current facility.

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 enrollee was admitted to the on hospital February 15, 2021 with severe infection and pancreatitis. The record sent by her provider indicates she has required mechanical ventilatory support and underwent tracheostomy and feeding tube placement. She has required multiple surgeries to remove part of her intestine, remove dead and damaged pancreas tissue, and wash out her abdomen. Her most recent surgery was 4 days ago (March 22, 2021). She has required a thoracentesis and blood pressure support. She is off the ventilator presently; breathing through her tracheostomy. 

There is no documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. 

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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Myrbetriq 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 is excluded from coverage.

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 Myrbetriq for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Prilosec 20mg tablet medication.

You asked the Plan to pre-approve this medication. You say that this medication is medically necessary for the enrollee. The Plan denied your request. The Plan says the medication is not a covered benefit under the enrollee's contractual policy.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drug requested here is not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve the Prilosec 20mg tablet medication.

Benefits for this medication 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: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Ilumya.

You asked the Plan to pre-approve Ilumya. You say that the enrollee has tried Ilumya in the past and improved. The Plan denied your request. The Plan says that step therapy criteria 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 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 Ilumya. Our reviewer says that the criteria for coverage of Ilumya have been met. Our physician reviewer found the Plan requires a trial of Inflectra or Renflexis before they will approve the requested drug, but step therapy may only be applied to new prescriptions or administrations of Part B drugs for enrollees that are not actively receiving the affected medication. In this case the patient has previously had treatment with Ilumya with success. The requested medication is medically necessary and reasonable.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Ilumya have been met. Therefore, we decided that the Plan has to pre-approve Ilumya.

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: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve Fluorodeoxyglucose (FDG) Positron Emission Tomography (PET) scan of the whole body.

You asked the Plan to pre-approve the FDG PET scan. You say that this imaging is needed to ensure no cancer remains. The Plan denied your request. The Plan says that this is not covered for this indication.

The Plan must follow Medicare rules. Medicare rules say that PET 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 the FDG PET scan. Our reviewer says that the requested imaging is shown to be reasonable and necessary in this case. Our physician reviewer found the enrollee was diagnosed with a Merkel cell carcinoma tumor in 2018. This was resected with radiation being completed in 2019. The provider wishes to perform this PET scan to ensure there is no residual cancer, or recurrent disease. 

Three PET scans are covered by Medicare for subsequent treatment strategy after initial treatment of all solid tumors. The criteria for this imaging are therefore met 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 the FDG PET scan have been met. Therefore, we decided that the Plan has to pre-approve Fluorodeoxyglucose (FDG) Positron Emission Tomography (PET) scan of the whole body.

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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental placement of implants on teeth #3 and #4 to be provided by an out-of-network dentist.

You asked the Plan to pre-approve dental services. You say that this provider performed a very successful procedure in the past and is very professional and cost-effective. The Plan denied your request. The Plan says the denial of authorization for these services is correct, because dental services are not covered when received from an out-of-network 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 out-of-network dentist. Therefore, we decided that the Plan does not have to pre-approve dental placement of implants on teeth #3 and #4 to be provided by an out-of-network dentist.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve apicoectomy - anterior (D3410).

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered benefit.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve apicoectomy - anterior (D3410).