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

We decided that the Plan does not have to pre-approve a carotid stent placement.
You asked the Plan to pre-approve the requested services. You say that the stent procedure is safer to prevent a
major stroke. The Plan denied your request. The Plan says you do not have a comorbid condition that is
indicated for a carotid stent.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the requested services. Our physician
reviewer found that you have a history of peripheral arterial disease.
You had a recent stroke, and a high grade right carotid artery stenosis was identified. You have a severe
symptomatic carotid stenosis but no documentation of high risk features. Specifically, you do not have
documented congestive heart failure, reduced ejection fraction, unstable angina, recent myocardial infarction,
contralateral carotid occlusion, prior neck radiation, or previous carotid endarterectomy with restenosis.
Therefore, the documentation does not support that any coverage criteria above for carotid stenting are 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 requested services have not been met. Therefore, we decided that the Plan
does not have to pre-approve a carotid stent placement.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laboratory work provided on September 25, 2019.You asked the Plan to waive the copayment for the laboratory work. You say that you met your out-of-pocket maximum amount for the year.  The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.The rules say a plan must disclose to its enrollees in clear, accurate termsall cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 copayment per day, per provider, for in-network Medicare-covered lab services. You have been asked to pay a $20 copayment for the laboratory work. The laboratory work falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The record shows you had met $1,850.76 of your maximum out-of-pocket amount when the laboratory work was processed.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 forthe laboratory work provided on September 25, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean Apple iPhone 11.You asked the Plan to pre-approvethe iPhone 11. You say that the iPhone 11 is medically necessary for Cardiac Monitoring.The Plan denied your request. The Plan says cellular phones are not a covered benefit.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. The Apple iPhone 11 does not have FDA approval for use as a Medical Device.Therefore, we decided that the Plan does not have to pre-approvean Apple iPhone 11.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services for enrollee.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee requires close physician monitoring, rehab therapy, and frequent respiratory therapy. The Plan denied your request. The Plan says the enrollee is receiving appropriate care at the current 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 physician reviewer found that the enrollee was admitted and treated at the current acute care facility with COPD exacerbation. Mechanical ventilation was needed as well as antibiotics for pneumonia due to permanent tracheostomy failure and difficulty clearing secretions. Acute renal failure was diagnosed during the hospitalization, however, recent records show improvement in renal function. Also, notes state that switching from Shiley to Jackson trach device has helped and the patient was stable until a recent mucus plug requiring going back on mechanical ventilation which should be short-term based on the clinical pattern. Although pulmonary care is still warranted at an acute care facility for the short term, long-term acute care is not likely to be needed and transfer to LTACH would not provide any needed treatments not already being provided and covered in the current setting. Therefore, based on the most recent records, this request for LTACH services will be considered not 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 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 for enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forhearing aids purchased on July 18, 2019.You asked the Plan to pay forthe hearing aids. Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Planpays for hearing aids only when purchased through in network. We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met.Therefore, we decided that the Plan does not have to pay forhearing aids purchased on July 18, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says there are no medical issues that require a rehab physician three times a week, or an intensive multi-disciplinary team approach to therapy.
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 physician reviewer found that the enrollee's medical conditions appear stable. There is no complex wound care needs. There are no unaddressed medical issues. She does not require medical oversight of her condition at an acute hospital level of care. She is ambulating greater than household distances and is performing essential activities of daily living without hands-on assistance, and does not require an intensive rehabilitation therapy program. 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia (J0897).You asked the Plan to pre-approve the Prolia. You say that Proliais medically necessary due to the member's conditions. The Plan denied your request. The Plan says the member does not meet step therapy exception criteria.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 Prolia. Our reviewer says that the member has not tried and failed a bisphosphonate. Our physician reviewer found based on the documentation provided, a bisphosphonate would likely be equallysafe and effective for this member.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 Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia (J0897).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe insertion of interlaminar/interspinous process stabilization/distraction device (22869 and 22870).You asked the Plan to pre-approvethe insertion of interlaminar/interspinous process stabilization/distraction device. You say that this procedure would provide significant clinical and quality of life improvements for the enrollee.The Plan denied your request. The Plan says this is experimental.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the insertion of interlaminar/interspinous process stabilization/distraction device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found current evidence based medical guideline and peer reviewed literature do not fully support the spinal decompression device procedure over the standard of lumbar laminectomy. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of this device for this enrollee's medical condition. Additionally, there is evidence of a grade 1 anterolisthesis at L4/5 with no documentation of flexion/extension x-rays confirming the absence of spinal instability. There is no documentation that the enrollee's body mass index is under 40. There is no documentation of a DEXA scan ruling out osteoporosis in this post-menopausal female. Therefore, this request for insertion of an interlaminar/interspinous process stabilization/distraction device (CPT codes 22869 and 22870) is not 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 insertion of interlaminar/interspinous process stabilization/distraction device have not been met.Therefore, we decided that the Plan does not have to pre-approvethe insertion of interlaminar/interspinous process stabilization/distraction device (22869 and 22870).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a cardiovascular nuclear stress test.You asked the Plan to pre-approve the stress test. You say that the stress test is medically necessary.The Plan denied your request. The Plan says medical necessity criteria have not been met as the member is able to exercise.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the stress test. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the member has increased coronary risk and nonanginal chest pain with a normal electrocardiogram. Based on the records the chest pain does not have documented features concerning for possible angina. Though there is mention of chronic ischemic heart disease this is not detailed further and there is no documentation of prior stress testing or coronary procedures.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 stress test have not been met. Therefore, we decided that the Plan does not have to pre-approve a cardiovascular nuclear stress test.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Amitiza.You asked the Plan to pre-approve Amitiza. 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 Part D prescription drug plan.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 Amitiza.Benefits for Amitizamay 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-approve custom foot orthotics on the enrollee.
You asked the Plan to pre-approve foot orthotics. You say that the enrollee has had numerous toe infections.
The Plan denied your request. The Plan says the services are not covered.
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 custom
foot orthotics on the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe endosteal implants provided on September 23, 2019.You asked the Plan to pay for the endosteal implants. You say that you were told by several plan representatives that these services would be covered at 50%. You also say that it was not verified how much you had accumulated for your annual maximum limit.The Plan denied your request. The Plan says the annual maximum benefit had been reached for this claim. The Plan also says that any portion of this service line in excess of the maximum will be your responsibility.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 Plan offers a $1000 annual dental benefit maximum. The record shows that you met the annual deductible benefit on September 23, 2019 and your annual deductible benefit has been exhausted.Therefore, we decided that the Plan does not have to pay fortheendosteal implants provided on September 23, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone marrow aspirate for use in an approved spinal fusion surgery.You asked the Plan to pre-approve the bone marrow aspirate. You say that this surgery is needed.The Plan denied your request. The Plan says all the procedures have been approved aside from the bone marrow aspirate as this is not proven effective.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the bone marrow aspirate. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found This enrollee is indicated for staged anterior cervical discectomy and fusion and posterior instrumented fusion at C3-C7. Under consideration is a request for bone marrow aspirate. There is no specific indication provided to support the request for bone marrow aspirate for the approved surgery. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of bone marrow aspiration in conjunction with the planned cervical spine surgery. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of bone marrow aspirate for this enrollee's medical condition as discussed above. Therefore, the request fo rbone marrow aspirate is not medically reasonable and necessary for the approved cervical fusion.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 bone marrowaspirate have not been met.Therefore, we decided that the Plan does not have to pre-approve bone marrow aspirate for use in an approved spinal fusion surgery.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay foran office visit and outpatient lab work provided on September 16, 2019 by an out of network (OON) provider.You asked the Plan to pay foran office visit and outpatient lab work. You say that you would like reconsideration of payment for this claim.The Plan denied your request. The Plan says there are in-network providers available 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 foran office visit and outpatient lab work provided on September 16, 2019 by an out of network (OON) provider
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approveZarxio.You asked the Plan to pre-approveZarxio. You say that this is medically necessary.The Plan denied your request. The Plan says Neupogen is acceptable for the enrollee.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 Zarxio. Our reviewer says that the criteria for coverage of Zarxio have not been met. Our physician reviewer found the Plan requires a trial of Neupogen (filgrastim) AND Nivestym (filgastim-aafi) before they will approve the requested drug.  The documentation does not show that the enrollee has tried and failed Neupogen (Filgrastim) and Nivestym (Filgastim-aafi) or that these drugs would likely be less effective or 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 Zarxio have not been met.Therefore, we decided that the Plan does not have to pre-approveZarxio.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician's services to be provided by the doctor.You asked the Plan to pre-approve the physician's services. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan. 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 providerwith the Plan. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require thePlan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approvephysician's services to be provided by the doctor.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) for the enrollee.
You asked the Plan to pre-approve SNF services. You say that rehab would allow for the enrollee to progress towards his baseline. The Plan denied your request. The Plan says that the enrollee's needs can be met at a lower level of care.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for SNF services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) for the enrollee.