Persius/hicric huggingface dataset:
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approveProlia (J0897).You asked the Plan to pre-approveProlia. You say that this is medically necessary.The Plan denied your request. The Plan says step therapy criteria have not been met.Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Prolia. Our reviewer says that the criteria for coverage of Prolia has not been met. Our physician reviewer found the Plan requires either a history of osteoporotic fracture or a trial of zoledronic acid before they will approve the requested drug. The enrollee does not have a history of an osteoporotic fracture and has not tried and failed zoledronic acid.  The documentation does not support that zoledronic acid 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 Prolia have not been met.Therefore, we decided that the Plan does not have to pre-approveProlia (J0897).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the podiatry services provided on March 16, 2020.
You asked the Plan to waive the copayment for the podiatry services. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received podiatry services on the date of service at issue in this appeal. The Plan says that the correct copayment has applied per your contract with the Plan.
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 a $25 copayment for Podiatry services. We looked at the file, the Plan's contract and Medicare rules. The file shows that you received podiatry services on March 16, 2020. You have been asked to pay a $25 copayment for the podiatry services. The podiatry services fall within the Podiatry services benefit category. 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 the podiatry services provided on March 16, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Enhertu.
You asked the Plan to pre-approve Enhertu. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug 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 looked at the file and Medicare rules. Review of the file shows that there were no medical records submitted to support that the requested drug is medically necessary or reasonable. Based on this information, we decided that Medicare rules for coverage of Enhertu have not been met. Therefore, we decided that the Plan does not have to pre-approve Enhertu.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveEliquis tablets.You asked the Plan to pre-approveself-administered drugs. You say that you are appealing.The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because this drug is not covered by Medicare Part B and the Plan does not administer the enrollee's Medicare Part D prescription drug benefits.The Plan must follow Medicare rules. The rules say that Medicare PartB 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-approveEliquis tablets.Benefits for self-administered drugsmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the neck spine (72141).
You asked the Plan to pre-approve an MRI of the neck spine. You say that the service is 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. 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 an MRI of the neck spine. Our reviewer says that the service is not medically necessary. Our physician reviewer found while there would be obvious clinical concern in light of the prior fusion at C6-7 the evaluation by the referring clinician on June 2, 2020 does not reveal any detailed neurological examination. There is a lack of not only any red flags to mandate immediate cervical spine imaging, no plain films were done either. It is also unusual that a neurosurgeon would not see an enrollee in whom prior fusion was performed without first going through the primary care physician (PCP). In any case, the submitted records do not provide evidence the requested MRI is medically reasonable and necessary at this point. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an MRI of the neck spine have not been met. Therefore, we decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the neck spine (72141).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs this to recover fully. The Plan denied your request. The Plan says the enrollee's needs are met in the current setting.
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 based on the provided medical records, the patient is receiving all necessary services in the present acute care hospital. Continued care at this level is appropriate until the patient is stable to transfer to a lower level of care such as an inpatient rehabilitation facility, a skilled nursing facility, sub-acute rehabilitation facility, or home with home health 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 the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve image guided radiation therapy (IGRT) (G6002, G6013).You asked the Plan to pre-approve IGRT. You say that the services are necessary.The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not been met.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 IGRT. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found it seems as though IGRT is simply being used as routine practice, as there does not seem to be any exceptional circumstances with this enrollee necessitating the need for IGRT.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IGRT have not been met.Therefore, we decided that the Plan does not have to pre-approve image guided radiation therapy (IGRT) (G6002, G6013).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe specialist visit provided on January 8, 2020.You asked the Plan to waive the copayment forthe specialist visit. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request.The Plan denied your request. The Plan says you received services provided by a specialist on the date of service at issue in this appeal. The Plan says that the correct copayment has applied per your contract with the Plan.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 a $35 copayment for each specialist visit for Medicare-covered services. We looked at the file, the Plan's contract and Medicare rules. The file shows that you received services provided by a specialist on January 8, 2020. You have been asked to pay a $35 copayment for the specialist visit. The specialist visit falls within the Physician/Practitioner services benefit category. 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 specialist visit provided on January 8, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued home health services.
You asked the Plan to pre-approve home health services. The Plan denied your request. The Plan says the enrollee's current needs do not appear to be skilled in nature.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 home health services. Our physician reviewer found that the enrollee does not have new enteral feedings, complex wound care, or other skilled nursing needs. His conditions are chronic and stable and do not require ongoing skilled nursing services. The enrollee's functional level and training in a home exercise program do not indicate he requires the ongoing skills of a physical therapist. The records do not show that skilled nursing or therapy services are required to effectively provide treatment, care, or services in order to improve the enrollee's condition; or to establish/perform a maintenance program to maintain the enrollee's condition or prevent deterioration. Additionally, without the need for skilled services such as SN or skilled therapies home health aide services would also not be considered medically necessary for the treatment of the enrollee's illness or injury by the skilled professional staff.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued home health services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from December 7, 2019 to January 6, 2020.You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act.The Plan denied your request. The Plan says the enrollee did not require daily skilled nursing and/or rehabilitation services on a daily basis.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 carefullyreview the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the skilled nursing services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 skilled nursing services have not been met.Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided from December 7, 2019 to January 6, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve.You asked the Plan to pre-approvethe requested drugs. You say that the enrollee received 25 units of blood and has a serum level over 1.000 mcg/L.The Plan denied your request. The Plan says the enrollee does not need iron chelating therapy at this time.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 the requested drugs. Our physician reviewer found that the enrollee has myelodysplastic syndrome and transfusion-dependent anemia. The records showed evidence of transfusion of more than 20 units of packed red blood cells over the past several months.  No laboratory report documenting the ferritin level was included in the available records. A bone marrow biopsy reported increased storage iron. The documentation does not support that the requested drug is medically reasonable and necessary for the enrollee. The  documentation does not support that the requested drug is safe and effective for 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 the requested drugs have not been met. Therefore, we decided that the Plan does not have to pre-approve
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says there are no noted daily skilled complex nursing or therapy needs.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.Continued SNF services beyond May 28, 2020 were requested. 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 physician reviewer found that from a nursing perspective, you had stable vital signs. You were treated for pain with effect. There are no identifiable skilled nursing service needs. Regarding rehab services, you were at contact guard assist with functional mobility. You required varying assist with activities of daily living. There are no identifiable skilled therapy service needs. You do not require skilled nursing or therapy services on a daily basis. 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 continued skilled nursing facility (SNF) services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to you by an out-of-network provider on January 12, 2020.You asked the Plan to pay for the services. You say that you are having trouble finding in-network providers.The Plan denied your request. The Plan says the services were not authorized.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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services.Therefore, we decided that the Plan does not have to pay for the medical services provided to you by an out-of-network provider on January 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the removal of impacted tooth and consultation provided on January 29, 2020.
You asked the Plan to pay for the removal of impacted tooth and consultation. You say that you should not be liable for this bill because a Plan representative told you that it would be covered. The Plan denied your request. The Plan says the treating provider has been identified as an opt out provider and may not receive Medicare payment for the services rendered.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the treating provider. This provider has opted out of the Medicare program. The file shows that this provider entered into a private contract with you regarding payment. Therefore, we decided that the Plan does not have to pay for the removal of impacted tooth and consultation provided on January 29, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute IRF admission and services.You asked the Plan to pre-approveIRF care. You say that the enrollee requires aggressive therapy, and close physician monitoring.The Plan denied your request. The Plan says the enrollee does not require intensive, complex, interdisciplinary therapy in the acute inpatient 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 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 is generally medically stable after a small stroke, with no evidence of complex medical issues that require monitoring by an inpatient rehab physician three times per week, or need for acute rehab nursing care. Currently the enrollee is at contact guard to standby assist for activities of daily living and mobility. While the enrollee may benefit from continuing physical and occupational therapy, there is no evidence of need for an intensive therapy program with therapy 3 hours per day with frequent physician oversight and an interdisciplinary approach to rehabilitation 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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveadmission to a long term acute care hospital (LTACH) for the enrollee.You asked the Planto pre-approvethe LTACH services. You say that this is medically necessary.The Plandenied your request. The Plansaysthe services could be provided in another setting, such as an acute rehabilitation facility facility, skilled nursing facility, nursing facility, outpatient setting, or home care.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 andnecessary in this case. Our physician reviewer found the review has determined that the enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no services availableat the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.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-approveadmission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eyeglasses provided on February 6, 2020.
You asked the Plan to pay for the eyeglasses. You say that you were never told you could not go to this
provider for your eyeglasses and if you were told that you would not have gone there. The Plan denied your
request. The Plan says you must use a Plan optical facility for coverage of eyewear.
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear
benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
We looked at the file and the Plan's rules. The provider at issue in this case is not an in-plan optical provider.
Based on this information, we decided that the Plan's rules for coverage of the eyeglasses have not been met.
Therefore, we decided that the Plan does not have to pay for eyeglasses provided on February 6, 2020.