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

We decided that the Plan does not have to pre-approve a Group 1 standard power wheelchair and accessories.You asked the Plan to pre-approve a Group 1 standard power wheelchair. You say that you cannot stand for more than 5 or 10 minutes so you are forced to be homebound.The Plan denied your request. The Plan says the record shows you have full strength and mobility of your upper extremities, and your doctor did not write an order for a power mobility device.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. The file does not show you have a mobility deficit that impairs your participation in MRADLs or that your condition cannot be improved by a walker, cane or manual wheelchair. The item at issue in this appeal is being requested for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan cover PMDs for use only outside the home. Also, there is no physician order. This means that Medicare rules for coverage of a PMD have not been met.Therefore, we decided that the Plan does not have to pre-approve a Group 1 standard power wheelchair and accessories.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Durolane.You asked the Plan to pre-approve Durolane. You say that the requested Durolane is medically necessary.The Plan denied your request. The Plan says the enrollee has not tried and failed the preferred drugs Monovisc and Orthovisc first.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 Durolane. Our reviewer says that the Plan's step therapy criteria have not been met. Our physician reviewer found the enrollee is with a diagnosis of bilateral primary osteoarthritis of the knees. The documentation does not show that the enrollee has tried and failed Monovisc and Orthovisc first. The documentation does not support that Monovisc and Orthovisc would likely be less effective, and/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 Durolane have not been met.Therefore, we decided that the Plan does not have to pre-approve Durolane.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approveultrasound therapy to be provided by the provider.You asked the Plan to pre-approveultrasound therapy. You say that you really need this treatment for your condition.The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this service is not covered by Medicare or the Plan when performed by a chiropractor.The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pre-approveultrasound therapy to be provided.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cardiac computed tomography and angiography (CCTA) for calcium screening.You asked the Plan to pre-approve these services. You say that the enrollee needs to be assessed for coronary artery disease.The Plan denied your request. The Plan says the services are not covered.The Plan must follow Medicare rules.The rules say that Medicare does not cover a screening CCTA for  quantitative evaluation of coronary calcium.We looked at the file and Medicare rules. The CCTA is being requested for quantitative evaluation of coronary calcium. These services are not covered by Medicare.Therefore, we decided that the Plan does not have to pre-approve cardiac computed tomography and angiography (CCTA) for calcium screening.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 140mg of Repatha (J3590).You asked the Plan to pre-approve the Repatha. You say that the member has tolerated Raptha well since starting it and it has worked remarkably well. The Plan denied your request. The Plan says this service should be processed under Medicare Part D.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 140mg of Repatha (J3590). Benefits for the Repatha 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 porcelain crown fused to high noble metal (D6750) for teeth # 29 and 31, and a porcelain pontic fused to high noble metal (D6240) for tooth # 30.You asked the Plan to pre-approve the dental services. The Plan denied your request. The Plan says posterior fixed bridges are beyond the scope of coverage.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 bridges are a covered service, they are only covered to replace anterior teeth. The record shows that the teeth you are requesting a bridge for are posterior teeth.Therefore, we decided that the Plan does not have to pre-approve a porcelain crown fused to high noble metal (D6750) for teeth # 29 and 31, and a porcelain pontic fused to high noble metal (D6240) for tooth # 30.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve a tempo-mandibular joint (TMJ) splint, and continued care with. You asked the Plan to pre-approve the specialist service. You say that you have found a TMJ dentist that has helped the pain in your lower jaw. You say that you have seen 2 other TMJ dentists that were in network and treated you with no success.The Plan denied your request. The Plan says that the services that you requested can be provided in network. The Plan also says that the services are not urgent or emergent.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 Plan did not provide a copy of the applicable Evidence of Coverage for this case. We asked for this document but it was not provided to us. Without this information we cannot determine that the Plan's coverage rules support the denial of payment in this case, or that the enrollee has been adequately notified of the Plan's coverage rules and benefits. Therefore the Plan has not substantiated their denial of payment in this case.Therefore, we decided that the Plan has to pre-approve a tempo-mandibular joint (TMJ) splint, and continued care.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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.You asked the Plan to pre-approve foot orthotics. You say that the enrollee needs custom orthotics to avoid additional foot problems.The Plan denied your request. The Plan says this item is not a covered benefit.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 their condition.Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea shower chair.You asked the Plan to pre-approvea shower chair. You say that the enrollee needs the requested bench to safely bathe in her home. You say that she is at risk of falls and the bench is a requirement for the enrollee.The Plan denied your request. The Plan says this item is not a covered benefit.The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item.Therefore, we decided that the Plan does not have to pre-approvea shower chair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea partial lower denture with a resin base (D5212).You asked the Plan to pre-approvethe dental item. The Plan denied your request. The Plan says a partial denture with a resin base is not a covered 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.Though the Plan offers a dental benefit in excess of Medicare coverage, a partial denture with a resin base is not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approvea partial lower denture with a resin base (D5212).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not haveto pre-approve Supartz FX injection.You asked the Plan to pre-approve the injection. You say that this is medically necessary.The Plan denied your request. The Plan says there is no evidence of a trial and failure of Monovisc and Orthovisc.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 injection. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found the provided medical records do not indicate that the patient has tried and failed the required drugs. The provided medical records do not indicate that the Plan's required drugs would likely be less effective and/or likely have adverse effects 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 injection have not been met.Therefore, we decided that the Plan does not haveto pre-approve Supartz FX injection.
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 the enrollee really needs the diapers as he has to change them daily.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 Feraheme infusions.
You asked the Plan to pre-approve the Feraheme. You say that the enrollee needs this treatment for his anemia. The Plan denied your request. The Plan says there is no evidence of iron deficiency being the cause of anemia and no known intolerance to oral iron supplementation.
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 Feraheme. Our reviewer says that the requested treatment is not considered medically necessary in this case. Our physician reviewer found documentation does not support the enrollee has anemia of chronic disease or intolerance to oral iron replacement. The documented hemoglobin and hematocrit levels do not support a diagnosis of anemia. Without the support of the documentation, medical necessity cannot be determined. 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 Feraheme have not been met. Therefore, we decided that the Plan does not have to pre-approve Feraheme infusions.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve a Trelstar injection You asked the Plan to pre-approve the Trelstar. You say that the Trelstar is medically necessary. The Plan denied your request. The Plan says that this medication is considered medically necessary based on stage of prostate cancer. Because no prostate cancer stage was provided, the requested medication is not indicated. 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 Trelstar. Our reviewer says that the member meets Medicare coverage criteria for the injection. Our physician reviewer found Trelstar is approved per the NCCN compendia for advanced prostate cancer. Additionally, it appears that this is a continuation of services with a positive response.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 Trelstar have been met. Therefore, we decided that the Plan has to pre-approve a Trelstar injection 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IVC filter removal surgery to be provided at the requested medical center.You asked the Plan to pre-approve the IVC filter removal surgery. 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 pre-approved care. The requested medical center in this case is not a network provider with the Plan. The Plan has an in-network medical center available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve the requested services. Therefore, we decided that the Plan does not have to pre-approve IVC filter removal surgery to be provided by the out-of-network medical center.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve periodic x-ray exams while out of area (OOA).
You asked the Plan to pre-approve the OOA radiology services. You say that the enrollee needs to continue post-operative management with radiology services while she is out of the service area. The Plan denied your request. The Plan says the request for non-urgent OOA services is not approved as this is not covered by the Plan.
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and pre-approved care. In this case, the requested services are not considered urgently needed as they do not meet the unforeseen criterion. As the need for this follow up is known prior to leaving the service area, it cannot be covered as urgently needed OOA care. Therefore, we decided that the Plan does not have to pre-approve periodic x-ray exams while out of area (OOA).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6545, A6549, A6441, A6452. You asked the Plan to pre-approve the compression stockings. You say that you have lymphedema in your legs. The Plan denied your request. The Plan says gradient compression stockings A6545, A6549, A6441, A6452 are non-covered when there is no qualifying wound. The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6545, A6549, A6441, A6452 are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that compression bandages and gradient compression wraps are covered only when they are used as dressings over a qualifying wound.The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you do not have a medical condition for which compression stockings can be covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6545, A6549, A6441, A6452.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve porcelain or ceramic retainer crowns (code D6740 x2) and a porcelain or ceramic pontic (code D6245) to be provided by you.
You asked the Plan to pre-approve the retainer crowns and pontic. You say that the enrollee is not able to eat because of her missing teeth. You also say that the enrollee would be able to eat and feel better with a bridge. The Plan denied your request. The Plan says the information does not say why a denture cannot be used to replace the enrollee's missing teeth.
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 retainer crowns and pontic 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 retainer crowns and pontic. Our reviewer says that the services are not medically necessary. Our physician reviewer found the provided x-rays show a mostly intact arch with the only two missing teeth being #19 and #30. Our reviewer found that the provided records do not indicate any limitations of the enrollee to wear a removable appliance, and it would be a simple partial denture design to replace #30 as well as #19 on such an appliance. Our physician reviewer also found that given the lack of support for the need for a fixed appliance, under the Plan there would be no medical necessity for the requested fixed bridge from tooth #'s 29 to 30. 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 retainer crowns and pontic have not been met. Therefore, we decided that the Plan does not have to pre-approve porcelain or ceramic retainer crowns (code D6740 x2) and a porcelain or ceramic pontic (code D6245) to be provided by you.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not haveto pre-approve placement of a Superion interspinous spacer device.You asked the Plan to pre-approve the Superion spacer. You say that this is a proven treatment that would be beneficial.The Plan denied your request. The Plan says the Superion spacer is not considered reasonable and necessary due to a lack of studies to support its use.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 Superion spacer. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the requested device is considered experimental. More research is needed at this time.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 Superion spacer have not been met.Therefore, we decided that the Plan does not have to pre-approve placement of a Superion interspinous spacer device.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient mental health services.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee can be safely managed at the outpatient level, with an increase in frequency of visits with the psychiatrist.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found based upon review of the records provided, you do not require partial hospitalization treatment and could be treated in a lesser restrictive setting, as you are not showing any suicidal or homicidal ideation, and are not showing any psychosis or aggressive behaviors. 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 inpatient mental health services.