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

We decided that the Plan does not have to pre-approve lab tests, radiologic examinations, and cerumen removal.
You asked the Plan to pre-approve the lab tests, radiologic examinations, and cerumen removal. You say that the services are medically necessary. The Plan denied your request. The Plan says screening tests are not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The lab and radiology services are being requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. The enrollee has not yet had a physician visit with the ordering physician. Therefore, we decided that the Plan does not have to pre-approve lab tests, radiologic examinations, and cerumen removal.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Botox (J0585).
You asked the Plan to pre-approve Botox. You say that this is medically necessary. The Plan denied your request. The Plan says coverage of this medication is the responsibility of the enrollee's prescription drug plan when it is supplied by a pharmacy.
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be brought to the office for administration. Since the medication does not represent an expense to the physician and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that the Plan does not have to pre-approve Botox (J0585).
Benefits for Botox 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: 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 services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has 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 in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the documentation does not support that the enrollee's nursing, medical and rehabilitation needs require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. It has not been demonstrated that there is a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided 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: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a magnetic resonance angiography (MRA) of the head, a magnetic resonance angiography (MRA) of the neck, and a magnetic resonance imaging (MRI) of the brain.

You asked the Plan to pre-approve the MRAs and MRI. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says that the requested services are 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. The case file has conflicting information. Some documentation shows that an MRI was being requested and some documentation shows that MRAs were being requested. The documentation is not clear exactly what was being denied in this appeal. Maximus requested clarification from the plan on two occasions without resolution. Therefore, we decided that the Plan has to pre-approve a magnetic resonance angiography (MRA) of the head, a magnetic resonance angiography (MRA) of the neck, and a magnetic resonance imaging (MRI) of the brain.

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 a mandibular partial denture and a complete maxillary denture.

You asked the Plan to pre-approve the mandibular partial denture and complete maxillary denture. You say that you would like help covering these services. The Plan denied your request. The Plan says dentures are not a covered benefit under your dental plan.

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 mandibular partial denture and a complete maxillary denture.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care.
You asked the Plan to pre-approve the continuation of SNF care. You say that you continue to need SNF care. The Plan denied your request. The Plan says SNF care is no longer medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the continuation of SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you are a 66-year-old female who received SNF care until April 26, 2021. There are no longer any identifiable skilled therapy service needs and no longer any identifiable skilled nursing service needs. In addition, you do not require skilled nursing or therapy services on a daily basis and do not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the continuation of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair with additional power seat options 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 criteria may be met for a simpler power wheelchair.

The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.

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 services. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found there is no evidence of significant spasticity that needs management with a power wheelchair accessory. There is no evidence of intermittent catheterization or that the enrollee is high risk of a pressure ulcer. The enrollee's left upper extremity strength and independence in feeding do not support that the enrollee requires an electrical connection between the wheelchair controller and two or more motors (E2311), expandable controller (E2377) and harness (E2313). An E2300 is not primarily medical in nature and does not meet Medicare medical necessity criteria.

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 pre-approve a power wheelchair with additional power seat options for the enrollee.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aranesp.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the step therapy requirement is not 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has stage IIIB chronic kidney disease and iron deficiency anemia. She has not tried and failed the Plan's require drug, Retacrit. The records do not show that the required drug would be contraindicated or less effective; therefore, Aranesp is not reasonable or medically necessary.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve Aranesp.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Neupogen.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied
your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that Neupogen is covered when specific criteria are
met.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that
the services are not medically necessary. Our physician reviewer found the enrollee has stage one T1aN0
adenocarcinoma of the lung with hypogammaglobulinemia and chronic steroids for cryptogenic pneumonia.
She is being treated with carboplatin, pemetrexed, and Keytruda. There is no evidence of fever. The enrollee
does not meet the criteria for coverage and the Neupogen is not reasonable or medically necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve Neupogen.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Udenyca (Q5111).
You asked the Plan to pre-approve Udenyca. You say that this request is medically necessary and reasonable.
The Plan denied your request. The Plan says that Udenyca is not being prescribed for a medically accepted
indication.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDAapproved
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 Udenyca. Our reviewer says that the
requested drug is medically necessary and reasonable. Our physician reviewer found that the enrollee is a 69-
year-old man who is receiving Cisplatin and radiation for a head and neck cancer. In this case, the enrollee has
hypoalbuminemia and is older than 65 years old which is recognized as having increased risks for febrile
neutropenia in cancer patients as indicated in relevant Medicare compendia. The requested service is being
used for a medically acceptable indication as defined by Medicare rules.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Udenyca have been met. Therefore, we decided that the Plan has to pre-approve
Udenyca (Q5111).
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 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 the
complexity of the nursing, medical and rehabilitation needs do not require an acute rehab hospital inpatient stay
with an interdisciplinary approach to rehabilitation care. The enrollee does not require treatment by multiple
therapies, including either physical therapy or occupational therapy, at an intensive rehabilitation therapy
program. The documentation does not support that the enrollee would meet criteria for admission to an acute
inpatient rehabilitation facility. There is no indication that the enrollee would require skilled rehabilitation in an
IRF, participating in rehab services 15 hours a week, under the supervision of a physician with at least 3 visits
weekly to regain or maintain his functional status. 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Monovisc.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that Monovisc is covered when specific criteria are met. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has osteoarthritis of the right shoulder. He received viscosupplementation injections to the right shoulder on May 22, 2020 and November 11, 2020. The most recent injection from November of 2020 was not effective. The records do not support that the criteria for coverage are met; therefore, Monovisc is not reasonable or medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve Monovisc.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies.
You asked the Plan to pre-approve incontinence supplies. You say that you wet your bed when you sleep. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gelsyn-3 (J7328).

You asked the Plan to pre-approve Gelsyn-3. You say that Gelsyn-3 is medically necessary. The Plan denied your request. The Plan says preferred Viscosupplements do not require prior authorization. The Plan also says that the provided documentation does not show that the enrollee has tried and filed the preferred drugs.

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 Gelsyn-3. Our reviewer says that Gelsyn-3 is not medically necessary. Our physician reviewer found the provided documentation does not indicate that the enrollee has not tried and failed the required drugs. The reviewer found that there is no indication that the Plan's required drugs would likely be less effective and/or likely have adverse effects for the enrollee. Therefore, the reviewer found that the requested drug, Gelsyn-3, is not medically reasonable or necessary. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Gelsyn-3 have not been met. Therefore, we decided that the Plan does not have to pre-approve Gelsyn-3 (J7328).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extraction (D7140) for tooth # 29 provided on November 16, 2020.

You asked the Plan to pay for the dental service. You say that you were advised that the denture would be paid out of your 2021 benefit. You say that that was when the denture would be done. The Plan denied your request. The Plan says there is an annual maximum benefit of $1,500 for covered dental services. The Plan also says that the maximum benefit has been exhausted.

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 and fillings are a covered service, the annual maximum benefit has been exhausted.

The Evidence of Coverage clearly states that after the annual maximum is exhausted, any remaining charges are your responsibility. Therefore, we decided that the Plan does not have to pay for the extraction (D7140) for tooth # 29 provided on November 16, 2020.
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 this is medically necessary. The Plan denied your request. The Plan says care could be received in another setting.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee 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 (ex. SNF/SAR). 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: 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 IRF care is medically necessary. The Plan denied your request. The Plan says rules for IRF care 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 in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee is a 72 year old female who was sent to the hospital directly from the podiatrist on April 19, 2021, for progression to wet gangrene of the right great toe which was amputated on April 20, 2021. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient's current medical condition does not require intensive physician or nursing supervision in an IRF. The patient may benefit from additional physical and occupational therapy but the documentation does not reveal that this therapy must be only on an intensive 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.