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

We decided that the Plan does not have to pre-approve Darbepoetin Alfa for the enrollee.
You asked the Plan to pre-approve Darbepoetin Alfa. You say that this is medically necessary. The Plan denied your request. The Plan says that the enrollee has not tried and failed Retacrit.
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 Darbepoetin Alfa. Our reviewer says that Darbepoetin Alfa is not medically reasonable and necessary for the enrollee in this case. The documentation does not support that the enrollee has tried and failed Retacrit or that it would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. Our physician reviewer found that the enrollee's condition does not meet criteria for Darbepoetin Alfa. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Darbepoetin Alfa have not been met. Therefore, we decided that the Plan does not have to pre-approve Darbepoetin Alfa for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Cimzia.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 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-approve Cimzia.Benefits for these servicesmay 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 for the enrollee.
You asked the Plan to pre-approve IRF care. You say that the services are medically necessary. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee was admitted to the hospital on December 30, 2019 with right foot pain and a toe ulcer. She underwent right toe amputation on January 10, 2020. The physical therapy note dated January 16, 2020 states she is able to walk 116 feet with assistance from two and a rolling walker and is wearing a post-operative shoe. She does not have complex medical, nursing, or rehabilitation needs that require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee is already ambulating more than one hundred feet and does not require an intensive therapy program 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 for the enrollee.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve venous sclerotherapy.You asked the Plan to pre-approve sclerotherapy. You say that you are appealing with records.The Plan denied your request. The Plan says that the denial of authorization for this service is correct, because this procedure is not medically necessary.The Plan follows Medicare rules. Medicare rules say that sclerotherapy treatment may be covered as medically necessary with a failed trial of conservative therapy, testing supports a covered condition, and if the service is performed by appropriately trained personnel.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 sclerotherapy. Our reviewer says that the enrollee meets the Medicare criteria for the requested sclerotherapy treatment. Our physician reviewer found the enrollee has failed conservative therapy and remains symptomatic with quality of life adversely affected. Therefore, this procedure is indicated and appropriate.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of sclerotherapy have been met.Therefore, we decided that the Plan has to pre-approvevenous sclerotherapy
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Relizorb in-line cartridge (B4105).
You asked the Plan to pre-approve Relizorb in-line cartridge (B4105). You say that the requested Relizorb in-line cartridge is medically necessary. The Plan denied your request. The Plan says the requested Relizorb in-line cartridge is not medically necessary.
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 Relizorb in-line cartridge (B4105). Our reviewer says that the requested Relizorb in-line cartridge is not medically necessary. Our physician reviewer found the enrollee is with a diagnosis of Exocrine pancreatic insufficiency due to her condition that resulted from adenocarcinoma of the pancreas. She is status post a pylorus-preserving Whipple procedure in 2017. The enrollee has been treated with chemotherapy and radiation, and is on chemotherapy for metastatic disease. A PEG/PEJ tube was placed in 2019. The enrollee receives continuous tube feeds through the J tube. The enrollee has symptoms of nausea, flatus, and explosive bowel movements. RELiZORB "showed improvement in her loose stools and help with the "explosive movements" that were impacting her daily life." RELiZORB is indicated to hydrolyze fats in enteral formula. There is a lack of sufficient clinical evidence in the medical literature to support the use of RELiZORB in this 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 Relizorb in-line cartridge (B4105) have not been met. Therefore, we decided that the Plan does not have to pre-approve Relizorb in-line cartridge (B4105).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Oxycodone HCL for the enrollee.
You asked the Plan to pre-approve this drug. You say that the enrollee needs this to help control pain so she can complete daily life activities. The Plan denied your request. The Plan says that drug coverage for the member is limited to Medicare Part B covered drugs only.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drug requested here is not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Oxycodone HCL for the enrollee.
Benefits for this drug 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.You asked the Plan to pre-approveSNF services. The Plan denied your request. The Plan says that your needs could be met with custodial care and physical and occupational therapy through Medicare Part B.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 your 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-approveskilled nursing facility (SNF) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a fluid circulating cold pad (CPT E0218).You asked the Plan to pre-approvethe fluid circulating cold pad. You say that the requested item is a critical part of your treatment. You say that you were diagnosedwith a broken pelvis. You say that this is a very painful recovery and that you need constant icing. You say that you are unable to walk and that the requested device allows you to have ice treatment throughout the day.The Plan denied your request. ThePlan says the item being requested is not a Medicare covered benefit.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. Medicare rules say that a fluid circulating cold padwith pump (E0218) will be denied as not reasonable and necessary.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the fluid circulating cold pad have not been met. Therefore, we decided that the Plan does not have to pre-approvea fluid circulating cold pad (CPT E0218)
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ondansetron for the enrollee.
You asked the Plan to pre-approve Ondansetron. The Plan denied your request. The Plan says that this is not covered under Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Ondansetron for the enrollee.
Benefits for Ondansetron 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a maxillary partial denture -flexible base.You asked the Plan to pre-approve the maxillary partial denture. You say that you have a metal allergy to titanium and cannot wear the last set you got. You also say that you have a bone disease and are lucky to pay the bills you do because of your income.The Plan denied your request. The Plan says this service is not covered under your benefit package.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-approvea maxillary partial denture -flexible base
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea referral to an out-of-network provider.You asked the Planto pre-approvethe referral. You say that you have an appointment next week.The Plandenied your request. The Plansaysthe care appears to be available in-network.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 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. We found no exception that would require the Plan to pre-approve these items/services.Therefore, we decided that the Plandoes not haveto pre-approvea referral to an out-of-network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the hernia repair provided on July 24, 2019.
You asked the Plan to waive the cost share for the hernia repair. You say that you didn't get a statement showing how your obligation was calculated. The Plan denied your request. The Plan says the cost share applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that your in-network deductible is $300. This is the amount you have to pay out-of-pocket before we will pay our share for your covered in-network medical services. Your contract with the Plan says that after your yearly deductible is met you must pay 10% for each Medicare-covered in-network outpatient hospital facility visit. The item or service you asked the Plan to waive the cost share for falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that your $300 deductible applies to outpatient surgery. This cost sharing is a contractual obligation that had not been met at the time the hernia repair was received on July 24, 2019. Therefore, the remaining amount of $173.35 was applied to your deductible.
Since you met your $300 deductible, you have also been asked to pay $445.81, which is 10% of the allowed amount for the hernia repair. The allowed amount is $4,458.07 (10% x $4,458.07 = $445.81). The total amount you owe is $619.16 ($173.35 + $445.81 = $619.16).
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 cost share for the hernia repair provided on July 24, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a cervical/facet joint block.
You asked the Plan to pre-approve the block. You say that this is medically necessary. The Plan denied your request. The Plan says Medicare does not approve these injections when there is a strong suggestion of a pinched nerve (radicular component).
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 block. Our reviewer says that the requested block are not considered medically reasonable and necessary in this case. Our physician reviewer found there is a diagnosis of cervical radiculopathy and spinal stenosis. Therefore, the criteria of the LCD is met, and the requested procedure is deemed 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 the block have not been met. Therefore, we decided that the Plan does not have to pre-approve a cervical/facet joint block.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services for the enrollee.
You asked the Plan to pre-approve IRF care. You say that the enrollee needs physical therapy, and is not ready
to be on her own at this time. The Plan denied your request. The Plan says the enrollee's condition is not
medically complex, and does not require an interdisciplinary approach to oversee rehab care.
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 current level of function is moderate assist with transferring from wheelchair to bed, standing
from edge of bed with moderate to maximal assist, bathing with maximal assist, maximal assist with toileting,
moderate assist with upper body dressing, and maximal assist with lower body dressing. The enrollee is
currently medically stable. There is no evidence of complex medical issues that require monitoring by an
inpatient rehab physician three times per week, or acute rehab nursing care. While she 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-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
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 to be closely
monitored in the correct level of care. The Plan denied your request. The Plan says the enrollee's needs can be
met in the current inpatient hospital.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found the enrollee is currently undergoing treatment at an acute care hospital (ACH) for a
toxic megacolon in the setting of a progressive neuromuscular disease. The enrollee was intubated/ventilated
upon admission. She underwent abdominal surgery and was subsequently extubated. The enrollee continues to
have problems with airway secretions, malnutrition and weakness. As LTACHs and ACHs are licensed to
provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee
can remain at the current ACH until such time no acute services are required. The enrollee can then be
transferred/discharged to a lower level of care for any ongoing long term care needs.
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services for the enrollee.
You asked the Plan to pre-approve IRF care. You say that the enrollee is not getting better like she should. The Plan denied your request. The Plan says the enrollee's medical condition is stable, with no need for an intensive rehab therapy program.
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 based on the medical records provided, the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does not require skilled physical therapy and occupational therapy in an intensive rehabilitation therapy program. There is no indication that the enrollee would be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a dental crown.
You asked the Plan to pre-approve the crown. You say that this is medically necessary to cover the tooth that had a root canal. The Plan denied your request. The Plan says the tooth must have 50% bone support to approve this service.
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. The Plan covers the crown when the services are medically necessary and reasonable. 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 crown. Our reviewer says that the requested dental services are not medically reasonable or necessary. Our physician reviewer found you presented with a request for a crown restoration on tooth #18. The original denial was based on there being less than 50% remaining bone around the tooth which would compromise its long term stability. A crown to root ratio of 1:1 or better is necessary to ensure that the support is adequate to keep the tooth stable over an extended period of time. The provided x-ray is unreadable and the bone level, or in fact the need for a crown due to structural breakdown, is not able to assessed. Without being able to assess the bone support or remaining structure of the tooth, there can be no finding of medical necessity for the requested procedure. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the crown have not been met. Therefore, we decided that the Plan does not have to pre-approve a dental crown.