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

We decided that the Plan does not have to pre-approve Magnetic Resonance Imaging (MRI) of the Pelvis (72195).
You asked the Plan to pre-approve the MRI. You say that the MRI is medically necessary. The Plan denied your request. The Plan says coverage criteria is not met.
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 MRI. Our reviewer says that the MRI is not medically necessary. Our physician reviewer found the enrollee reported ongoing hip pain following a motor vehicle collision three months prior. Plain film imaging did not identify a cause of the pain. The provider ordered an MRI to evaluate for occult fracture. The documentation does not discuss previous treatment or therapy trialed. Physical examination did not note limitation of movement. 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 MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve Magnetic Resonance Imaging (MRI) of the Pelvis (72195).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvefoot orthotics for the enrollee.You asked the Plan to pre-approvefoot orthotics. You say that the orthotics will control the stress of the plantar fascia.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 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-approvefoot orthotics for the enrollee
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sensors for use with interstitial continuous glucose monitoring (A9276) and transmitter, external for use with interstitial continuous glucose monitoring (A9277).
You asked the Plan to pre-approve the sensors and transmitter. You say that the member gets hypoglycemia. The Plan denied your request. The Plan says that these items are never covered by Medicare.
Medicare rules say that CGM devices covered by Medicare under the DME benefit are defined as therapeutic CGMs and codes A9276 and A9277 are used to describe the supplies used with a non-therapeutic CGM. We looked at the file and Medicare rules. Based on this information, we decided that you are requesting supplies for a non-therapeutic CGM. Medicare will only cover therapeutic continuous glucose monitors and supplies. Therefore, we decided that the Plan does not have to pre-approve sensors for use with interstitial continuous glucose monitoring (A9276) and transmitter, external for use with interstitial continuous glucose monitoring (A9277).
Appeal type: Lab
Decision: Partially Favorable

We decided that the Plan has to pay for the presumptive screening. We decided that the Plan does not have to pay for the definitive drug testing for 22 or more drug classes.
You asked the Plan to pay for the presumptive screening. You say that the documentation supports these services. The Plan says that the order does not include what specific drugs are requested for testing so these codes cannot be verified.
We decided that the Plan has to pay for the presumptive screening.
The Plan follows Medicare rules. Medicare rules say that lab testing may be covered when ordered by a treating provider. The file includes an order form in which a presumptive screening is ordered. A presumptive screening is not for any specific number of drugs or drug classes. An order of the screen is sufficient to support the intent of screening of any number of analytes. Therefore, we decided that the Plan has to pay for the presumptive screening.
We also decided that the Plan does not have to pay for the definitive drug testing for 22 or more drug classes.
The Plan follows Medicare rules. Medicare rules say that lab testing may be covered when ordered by a treating provider. The documentation does not include a description of what is included in the definitive drug panel ordered. It cannot be confirmed that testing for 22 or more drug classes was intended by the provider. Therefore, we decided that the Plan does not have to pay for the definitive drug testing for 22 or more drug classes.
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 acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the inpatient rehabilitation services are medically necessary. The Plan denied your request. The Plan says rules for coverage have not been 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 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 The patient would benefit from Physical and Occupational therapy but the documentation does not indicate that he requires this on an intensive rehabilitation therapy program level that is provided in an IRF. Services could be provided 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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a transport system option (K0108).
You asked the Plan to pre-approve the transport option (K0108). The Plan denied your request. The Plan says a transport option is not a covered benefit for any wheelchair. Medicare does not cover items that are for outside use only.
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pre-approve a transport system option (K0108).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Actemra for the enrollee.You asked the Plan to pre-approve Actemra. You say that this is being used to treat the enrollee's Polymyalgia Rheumatica.The Plan denied your request. The Plan says that Actemra is not covered for the enrollee's condition.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 Actemra. Our reviewer says that that Actemra is not medically reasonable and necessary for the enrollee in this case. Although Actemra is likely safe for the patient, based on review of the provided medical records and the Medicare-approved compendia, Actemra is not clearly effective for the patient's conditions. Our physician reviewer found that the enrollee's condition does not meet criteria for Actemra.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Actemra have not been met.Therefore, we decided that the Plan does not have to pre-approve Actemra for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out of network (OON) provider.You asked the Plan to pre-approve the compression wraps (A6545x2). You say that the member has been coming to you for years for their durable medical equipment (DME) and the in-network provider has failed to provide the requested DME. The Plan denied your request. The Plan says the record does not indicate why the member cannot receive this are from a network provider.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 requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the medical services to be provided by an out of network (OON) provider.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Rituxan injections.You asked the Plan to pre-approve the Rituxan injections. You say that the use of Rituxan is indicated due to failure of prednisone and mycophenolate.The Plan denied your request. The Plan says that there has been no failure of the plan's preferred step therapy medications. There is no evidence that the step therapy medications would be less effective.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 Rituxan injections. Our reviewer says that the requested use of Rituxan is considered reasonable and necessary in spite of step therapy requirements. Our physician reviewer found the enrollee has rheumatoid arthritis associated interstitial lung disease. She has failed to respond to treatment with prednisone and mycophenolate. The patient has not tried and failed the required drug(s) (Inflectra, Remicade, or Simponi Aria). The plan's required drug(s) would likely be less effective and/or likely have adverse effects for the enrollee because none of the plan's approved drugs are indicated or recommended for use for treatment of rheumatoid arthritis associated interstitial lung disease. Rituxan infusions for RA interstitial lung disease are 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 the Rituxan injections have been met.Therefore, we decided that the Plan has to pre-approve Rituxan 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the PT services provided on September 20, 2019 by an out of network (OON) provider.You asked the Plan to pay for the PT services. You say that you were instructed that services could still be provided by an out-of-network provider.The Plan denied your request. The Plan says the utilization of network providers is required unless the Plan pre-approves out-of-network services in non-emergent situations.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 pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay for the PT services provided on September 20, 2019 by an out of network (OON) provider
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Prolia injection for the enrollee.You asked the Plan to pre-approve the injection. You say that this is medically necessary.The Plan denied your request. The Plan says there has been no received documentation supporting the medical necessary for a step therapy exception.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 injection. Our reviewer says that the requested injection is not medically reasonable or necessary. Our physician reviewer found the enrollee has not trialed zoledronic acid. Step therapy, as outlined by the plan, requires these be trialed first. The documentation does outline contraindications or reason this medication was not considered. Without the support of the documentation, Prolia is not approved 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 the injection have not been met.Therefore, we decided that the Plan does not have to pre-approve a Prolia injection for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for wound debridement provided on September
13, 2019.
You asked the Plan to waive the copayment for wound debridement. You say that wound care does not qualify
for the outpatient surgery copayment. You say that the code should be wound care not wound surgery. The
Plan denied your request. The Plan says the copayment applied correctly.
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 $295
copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital, including
but not limited to hospital or other facility charges and physician or surgical charges.
You have been asked to pay $199, which is less than the standard $295 copayment for wound debridement.
Wound debridement falls within the "Outpatient Surgery and Other Medical Services Provided at Hospital
Outpatient Facilities and Ambulatory Surgical Centers" benefit category. Wound debridement is considered a
surgical procedure.
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 wound debridement provided on September 13, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvelong term acute care hospital (LTACH) services.You asked the Planto pre-approvethe LTACH services. You say that the enrollee needs ongoing fluid maintenance and would benefit from intensive therapy.The Plandenied your request. The Plansaysthe enrollee's condition is not likely to allow for participation in three daily hours of therapy.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 hospital on 2/2/2020 with congestive heart failure and atrial fibrillation after a recent coronary bypass surgery. Based on review of the available records, the patient does not meet criteria for IRF admission. The patient is medically not stable. He may benefit from further PT and OT but does not require an intensive therapy program at this point of time. IRF admission is not medically appropriate at this time based on his medical instability.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 Plandoes not haveto pre-approvelong term acute care hospital (LTACH) services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prednisone for the enrollee.

You asked the Plan to pre-approve Prednisone. You say that the enrollee has diagnosis of acute renal failure. The Plan denied your request. The Plan says that this medication is not covered under Part B.

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 Prednisone for the enrollee. 

Benefits for Prednisone 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-approvea grab bar.You asked the Plan to pre-approvea grab bar. You say that this is necessary to prevent future falls.The Plan denied your request. The Plan says this is not a covered item.The Plan covers all items that Medicare covers. Medicare rules state that grab bars are not covered because they are not primarily medical in nature. While a grab bar may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item.Therefore, we decided that the Plan does not have to pre-approvea grab bar.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia injection (J0897).You asked the Plan to pre-approveProlia injection. You say that the enrollee has been on long-term systemic steroid use and cannot tolerate oral bisphosphonate due to GERD.The Plan denied your request. The Plan says the records submitted do not support medically necessary.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 Prolia injection. Our reviewer says that this enrollee does not meet the Medicare criteria for coverage. Our physician reviewer found the provided records did not show any evidence of or report of having tried and failed zoledronic acid injections, as required. The required zoledronic acid injection would not likely be less effective or have adverse effects for the enrollee. GERD was listed which was why oral bisphosphonates would be inappropriate, however, injectable bisphosphonate derivatives such as zoledronic acid would not worsen GERD or be a contraindication for any of the other conditions listed in the enrollee's 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 Prolia injection have not been met.Therefore, we decided that the Plan does not have to pre-approveProlia injection (J0897).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve power wheelchair accessories: sheet metal pan, LED light package, LED head lamp, LED safety flasher, tool kit, backpack, hand control weather cover, and wheelchair jack.You asked the Plan to pre-approvethe power wheelchair accessories. You say that you put a lot of miles on your power wheelchair and you needit to be able to function safely outside.The Plan denied your request. The Plan says these accessories are not medically necessary.The Plan must follow Medicare rules. The rules state that for equipment tobe covered, it must be appropriate and needed for use inside the home. The rules state accessories for wheelchairs must be medically necessary.The items at issue in this appeal are for use outside of the home. Although theseitemsmay be helpful, neither Medicare nor the Plan covers equipment for use outside the home.The items at issue in this appeal do not serve a purpose that is primarily medical in nature. These items are available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approvepower wheelchair accessories: sheet metal pan, LED light package, LED head lamp, LED safety flasher, tool kit, backpack, hand control weather cover, and wheelchair jack.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for vision services provided on October 10, 2019 by an out of network (OON) provider.
You asked the Plan to pay for vision care. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained for these services.
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 pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for vision services provided on October 10, 2019 by an out of network (OON) provider.