Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approveexpandable controller, expandable controller harness, and electric connection.You asked the Plan to pre-approveexpandable controller, expandable controller harness, and electric connection. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested items are not a covered benefit.The Plan follows Medicarerules. Medicare rules say that power wheelchair accessories such as expandable controllers, expandable controller harnesses, and electrical connections are only covered for certain indications.We asked our physician reviewer to carefully review the casefile and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve expandable controller, expandable controller harness, and electric connection. Our reviewer says that the documentation does not support that the requested power wheelchair accessories are medically reasonable or necessary. Our physician reviewer found the documentation does not support a medical need to control the power options through the joystick, proportional input devices (e.g., mini-proportional or compact joysticks, touchpads, chin control, head control, etc.),non-proportional input devices such as a sip and puff, head array, etc., or a need to operate 3 or more powered seating actuators through the drive control. You have sufficient strength and function in the upper extremities to operate any powered seating devices with their individual switches.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of expandable controller, expandable controller harness, and electric connection have not been met.Therefore, we decided that the Plan does not have to pre-approveexpandable controller, expandable controller harness, and electric connection
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for electric stimulation therapy (97014) provided on October 21, 2019.
You asked the Plan to pay for the electric stimulation therapy. You say that you would like reconsideration because this code is valid for payment. The Plan denied your request. The Plan says CPT code 97014 is not valid for Medicare purposes and another code should be used for the reporting of, and payment for this service.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code 97014 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT code 97014 has a status code of I. This means that CPT code 97014 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the electric stimulation therapy have not been met. Therefore, we decided that the Plan does not have to pay for electric stimulation therapy (97014) provided on October 21, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveAjovy.You asked the Plan to pre-approvethese services. You say that you disagree with the denial.The Plan denied your request. The Plan says self-administered drugs are not a covered benefit.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pre-approveAjovy.Benefits for these servicesmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve HFE (hemochromatosis) gene analysis.
You asked the Plan to pre-approve HFE gene analysis. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the requested services are not medically necessary.
The Plan follows Medicare rules. Medicare rules say that gene analysis is only covered for certain indications.
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 HFE gene analysis. Our reviewer says
that the documentation does not support that the requested services are medically reasonable or necessary. Our
physician reviewer found the enrollee is noted to have mild polycythemia without evidence of iron overload.
The enrollee is presumed to be a carrier of a hereditary hemochromatosis gene, given that her son has
hereditary hemochromatosis. Confirming that the enrollee is a carrier of the hereditary hemochromatosis gene
should in no way affect the management of her mild polycythemia. The requested test is not shown to be
medically necessary to diagnosis or treat the enrollee.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of HFE gene analysis have not been met. Therefore, we decided that the Plan does
not have to pre-approve HFE (hemochromatosis) gene analysis.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eyewear provided to the enrollee on October 29, 2019.
You asked the Plan to pay for the eyewear. You say that this should be paid by the Plan. The Plan denied your request. The Plan says that this is denied because it was not obtained from a network provider.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when obtained from a provider in the Plan's vision vendor network.. We looked at the file and the Plan's rules. The file indicates the eyewear was not obtained from a provider in the Plan's vision vendor network. Based on this information, we decided that the Plan's rules for coverage of the eyewear have not been met. Therefore, we decided that the Plan does not have to pay for the eyewear provided to the enrollee on October 29, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecomputed tomography (CT) of the abdomen and pelvis.You asked the Plan to pre-approvethe CT scan. You say that the records provided support the need for the requested CT scan.The Plan denied your request. The Plan says the clinical notes do not show any indication for the requested CT scan.The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan wascorrect in denying the request to pre-approve the CT scan. Our reviewer says that the requested CT scan is not medically reasonable and necessary. Our physician reviewer found the enrollee is known to have IBS and short gut syndrome. The enrollee has beenexperiencing diarrhea, though it is unclear if it is changed from baseline and by one account it had resolved. Two recent abdominal examinations have been benign. There is no evidence that a past-due colonoscopy or stool studies have been performed.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 CT scan have not been met.Therefore, we decided that the Plan does not have to pre-approvecomputed tomography (CT) of the abdomen and pelvis.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aranesp.You asked the Plan to pre-approve Aranesp. You say that the requested Aranesp is medically necessary.The Plan denied your request. The Plan says the requested Aranesp is not medically necessary.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 Aranesp. Our reviewer says that the requested Aranesp is not medically necessary. Our physician reviewer found the enrollee is diagnosed with Myelodysplactic disease. The requested Aranesp is FDA-approved for the enrollee's diagnosis, but with adequate iron stores. Based on the documentation provided, the enrollee had low iron stores on labs performed 11/2019. There is no documentation that he is on iron or has had this repleted IV. They have not been rechecked. If iron is corrected he may not require Aranesp.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Aranesp have not been met.Therefore, we decided that the Plan does not have to pre-approve Aranesp.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric services.You asked the Plan to pre-approve the inpatient psychiatric services. You say that it is not safe to discharge the enrollee based on clinical presentation. The discharge plan is transfer to a Long-Term Structured Residential (LTSR) unit.The Plan denied your request. The Plan says the level of care being requested is not medically necessary.The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 inpatient psychiatric services. Our reviewer says that the enrollee does not meet the criteria for treatment in an acute inpatient mental health treatment facility beyond the date in question of April 8, 2020 forward and could have been treated in a lesser restrictive setting. Our physician reviewer found the enrollee was admitted to the acute inpatient psychiatric hospitalization on March 5, 2020 with Schizoaffective Disorder Bipolar Type and Attention Deficit Hyperactivity Disorder. Based upon review the records provided it was not expected this enrollee would improve in a reasonable period of time beyond the dates in question as she was not showing any dangerousness to self or others, being fairly even without aggressive behaviors. It did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the dates in question as the enrollee did not have any suicidal or homicidal thoughts, hallucinations or abnormal behaviors. It does not appear that active treatment was taking place beyond the date in question. It does not appear that the services for the dates in question were reasonably expected or medically necessary to improve the patient's condition or for the purpose of 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 the inpatient psychiatric services have not been met.Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric services.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Genvisc 850 for the enrollee.
You asked the Plan to pre-approve Genvisc 850. You say that the enrollee has had an inadequate response of cortisone injection. The Plan denied your request. The Plan says the enrollee has not had previous treatment, contraindication, or intolerance to Orthovisc and Monovisc.
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 Genvisc 850. Our physician reviewer found that the enrollee has bilateral primary osteoarthritis of the knees. The Plan requires a trial of Orthovisc and Monovisc before they will approve the requested drug. The documentation does not show the enrollee has tried and failed the required drugs. The documentation does not support that Monovisc and Orthovisc would likely 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 Genvisc 850 have not been met. Therefore, we decided that the Plan does not have to pre-approve Genvisc 850 for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Zilretta injections.
You asked the Plan to pre-approve Zilretta. You say that you have knee pain and cannot move around well. The Plan denied your request. The Plan says Zilretta is not intended for repeat injections.
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 Zilretta. Our physician reviewer found that you have osteoarthritis in both knees. You have had bilateral knee injections of Zilretta in August 2019. Additional intra-articular injections of both knees have been requested. However, Zilretta is not intended for repeat administration. Safety and efficacy of repeat administration has not been established. Therefore, the documentation does not support that Zilretta 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 Zilretta have not been met. Therefore, we decided that the Plan does not have to pre-approve Zilretta injections.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services for the enrollee.You asked the Plan to pre-approvethe LTACH services. You say that the enrollee requires daily physician services, long term antibiotics, and nutrition management.The Plan denied your request. The Plan says the enrollee is receiving appropriate care at the present acute care 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 physiian reviewer found that the enrollee is currently undergoing treatment at an acute care hospital (ACH) for lumbar osteomyelitis, endocarditis and bacteremia. The enrollee underwent mitral valve surgery and continues to receive a prolonged course of antibiotics. The enrollee does not appear to be currently intubated/ventilated. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH.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 cthe Plan does not have to pre-approvelong term acute care hospital (LTACH) services for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a tier exception for Albuterol 5mg Solution.You asked the Plan to pre-approve the tier exception. You say that the Albuterol is medically necessary.The Plan denied your request. The Plan says tier exceptions are not available for this drug.The Plan must follow Medicare rules. Medicare rules say that plans may allow a tier exception for Part D drugs. We looked at the file and Medicare rules. The drug at issue is not a Part D drug. It is not eligible for a tier exception. Based on this information, we decided that Medicare rules for coverage of the tier exception have not been met.Therefore, we decided that the Plan does not have to pre-approve a tier exception for Albuterol 5mg Solution.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a kidney and liver transplant.You asked the Plan to pre-approve a kidney and liver transplant. You say that the requested kidney and liver transplant is medically necessary.The Plan denied your request. The Plan says the requested kidney and liver transplant is not medically necessary at this time. The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a kidney and liver transplant. Our reviewer says that the requested kidney and liver transplant is not medically necessary at this time. Our physician reviewer found the enrollee is with diagnoses of non-alcoholic steatohepatitis, unspecified cirrhosis of the liver, and end-stage renal disease secondary to diabetic nephrosclerosis. Her medical history is also notable for poorly-controlled diabetes,neuropathy, atrial fibrillation, pulmonary hypertension, myonecrosis, GERD, GI bleeding, hypertension, and hyperparathyroidism. The Plan has denied coverage of the requested kidney and liver transplant, stating that the enrollee has significant pulmonary hypertension and has not been cleared for transplant by a pulmonologist, and also has atrial fibrillation with episodes of rapid ventricular response as well as prolonged QT interval, and has not been cleared for transplant by cardiologist. The TGMG Cardiology Advanced CHF/Transplant Consult dated 4/16/20 documents that the enrollee was cleared by the service for possible kidney/liver transplant. Arrhythmia management was deferred to the electrophysiology (EP) service.The documentation is insufficient to demonstrate that the requested kidney/liver transplant is medically reasonable and necessary for the enrollee in this case. The EP service and pulmonary services have not cleared the enrollee for such surgery. The enrollee was pending Watchman device placement as of 4/21/20. It is also noted that the enrollee's outpatient transplant evaluation was pending colonoscopy, which has been delayed indefinitely due to Covid-19.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 kidney and liver transplant have not been met.Therefore, we decided that the Plan does not have to pre-approve a kidney and liver transplant.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 27134, CPT 27065) provided on August 7,
2018.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services
cannot be verified.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
In this case, the CPT Code Manual definition of code 27134 is "Revision of total hip arthroplasty; both
components, with or without autograft or allograft". The CPT Code Manual definition of code 27065 is
"Excision of bone cyst or benign tumor, wing of ilium, symphysis pubis, or greater trochanter of femur;
superficial, includes autograft, when performed".
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 pay for the services. Our reviewer says that the use
of CPT codes 27134 and 27065 is not supported by the records provided. Our physician reviewer found that
while the polyethylene liner and the femoral head were replaced, neither the acetabular cup nor the femoral
stem were replaced. Therefore, the documentation does not support the billing of CPT 27134. While an
osteolytic lesion related to wear and tear was cleaned and filled, no cyst or being tumor was excised. Therefore,
the documentation does not support the billing of CPT 27065.
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 services have not been met. Therefore, we decided that the Plan does not
have to pay for the services (CPT 27134, CPT 27065) provided on August 7, 2018.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Zilretta.
You asked the Plan to pre-approve Zilretta. You say that the requested Zilretta is medically necessary. The Plan denied your request. The Plan says the requested Zilretta is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Zilretta. Our reviewer says that the requested Zilretta is not medically necessary. Our physician reviewer found this enrollee presents with a history of chronic right knee pain. She has been diagnosed with right knee osteoarthritis. Under consideration is a request for repeat Zilretta injection to the right knee. Records document that the enrollee has received a Zilretta injection to the right knee on 1/10/20 with reported benefit. The FDA indications state that Zilretta injections are not indicated for repeat administration as the efficacy and safety has not been demonstrated. Current evidence based medical literature notes recent study findings suggest a repeat Zilretta injection may be efficacious without deleterious effects, but further investigation with longer-term and/or placebo-controlled studies was recommended. Therefore, the documentation does not support that repeat Zilretta is medically reasonable and necessary or safe and effective for treatment of this enrollee's medical condition. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Zilretta have not been met. Therefore, we decided that the Plan does not have to pre-approve Zilretta.