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

We decided that the Plan has to pre-approve Zilretta.
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 that the services are 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 asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are medically necessary. Our physician reviewer found the records show that you have osteoarthritis of both knees. There is no evidence that you are allergic to this or related medications. There is no documentation that you have used this medication before. Zilretta is reasonable and medically necessary 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 these services have been met. Therefore, we decided that the Plan has to pre-approve Zilretta.
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 pay for the knee orthosis and suspension sleeve, and addition to lower extremity orthosis provided by Greenleaf Medical Supply on August 7, 2019.You asked the Plan to pay for the knee orthosis (L1833) and suspension sleeve (L2397), and addition to lower extremity orthosis (L2810). You say that the orthoses were medically necessary.The Plan denied your request. The Plan says criteria for the orthoses have 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 looked at the file and Medicare rules. There are no medical records, from the prescribing physician, on the date of order to support medical necessity. Based on this information, we decided that Medicare rules for coverage of the knee orthosis (L1833) and suspension sleeve (L2397), and addition to lower extremity orthosis (L2810) have not been met.Therefore, we decided that the Plan does not have to pay for the knee orthosis and suspension sleeve, and addition to lower extremity orthosis provided by Greenleaf Medical Supply on August 7, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan.
You asked the Plan to pre-approve these services. You say that you need the scan to assess cancer growth. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that PET scans 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the submitted records show that you have high-risk prostate cancer and a PET scan with Axumin is being requested for evaluation of the extent of the cancer. Axumin is used for suspected prostate cancer recurrence based on elevated prostate specific antigen (PSA) after prior treatment. The records show that you are untreated at this time; therefore, a PET with Axumin is not reasonable or medically necessary as it is not indicated for staging of initial disease. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe additional intraoral periapical x-ray provided on October 31, 2019.You asked the Plan to pay forthe additional intraoral periapical x-ray. You say that a Plan representative gave you this dental provider saying they were in-network. You also say that you checked again while you were at the appointment and they confirmed this provider was in-network.The Plan denied your request. The Plan says your 2019 EOC only provides a benefit for one periapical x-ray per calendar year and the benefit was exhausted.Medicare generally does not cover dentalservices. 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, intraoral x-rays are limited to oneprocedure per calendar year. The record shows that you received a first intraoral periapical x-ray on October 31, 2019 and your intraoral x-rays benefit was then exhausted.Therefore, we decided that the Plan does not have to pay forthe additional intraoral periapical x-ray provided on October 31, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the enrollee from March 31, 2019 to April 29, 2019.
You asked the Plan to pay for this service. You say that SNF services were medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria were not met.
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 pay for this service. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found based on the medical records provided, there were no identifiable daily skilled nursing or daily skilled therapy services required by the enrollee at a SNF level of care for the dates of service in question. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the enrollee from March 31, 2019 to April 29, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the panoramic x-ray (D0330), the immediate maxillary denture (D5130), the immediate mandibular denture (D5140), the removal of the torus mandibularis (D7473 x 2), and the surgical extractions (D7140 x 14) provided on July 17, 2019 by the out of network dentist.You asked the Plan to reimburse you forthe dental services. You say that before the enrollee received the services, you contacted customer service. You say that you were advised the enrollee had dental coverage. You say that nothing was said about needing to see an in network dentist. You say that the provider did not advise they were out of network. You also say that you are on a fixed income and this is a big expense.The Plan denied your request. The Plan says dental services are not covered when you receive them out of network. The Plan also says that the provider in this case is not a network provider.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, dental services that you receive out of network are not covered.Therefore, we decided that the Plan does not have to reimburse you forthe panoramic x-ray (D0330), the immediate maxillary denture (D5130), the immediate mandibular denture (D5140), the removal of the torus mandibularis (D7473 x 2), and the surgical extractions (D7140 x 14) provided on July 17, 2019 by the out of network dentist.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay forthe denosumab injection provided to the enrollee on August 20, 2019.You asked the Plan to pay forthese services. You say that this was medically necessary for the enrollee.The Plan denied your request. The Plan says that there was no documentation of high risk for fracture, defined as a history of osteoporotic fracture, or multiple risk factors for fractures; or failed intolerance to other available osteoporosis medicine therapy; or significant renal failure.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 pay for these services. Our reviewer says that the denosumab injection was not medically reasonable and necessary for the enrollee in this case. The enrollee is noted to have osteoporosis based on a November 2017 DEXA scan. The enrollee is noted to have been taking vitamin D,but not calcium. There is no indication that the enrollee had taken other osteoporosis medications and was either allergic, intolerant or non-responsive to them. Our physician reviewer found that the enrollee's condition did not meet criteria for coverageof the injection.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pay forthe denosumab injection provided to the enrollee on August 20, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveInfliximab-abda (Renflexis).You asked the Plan to pre-approveRenflexis. The Plan denied your request. The Plan says you have not had a positive clinical response to treatment.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 Renflexis. Our physician reviewer found that continued therapy of Renflexis for another 12 months has been requested. An office visit on December 3, 2019, indicates symptoms are worse. There is no improvement on imaging. You have not had a beneficial response to 1 year of infusion with Renflexis. Your symptoms have progressed, and spine imaging has not improved. Therefore, continued treatment is considered not medically necessary because of lack of clinical 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 Renflexis have not been met.Therefore, we decided that the Plan does not have to pre-approveInfliximab-abda (Renflexis).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve TAVR.You asked the Plan to pre-approve TAVR. You say that the member meets criteria for symptomatic severe aortic stenosis and TAVR. The Plan denied your request. The Plan says the member is suitable and low risk for surgical aortic valve replacement.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 TAVR. Our reviewer says that the reports did not sufficiently show a contraindication to open-valve aortic repair compared to the proposed TAVR. The member was documented as being low-risk for this procedure. Our physician reviewer found TAVR 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 TAVR have not been met. Therefore, we decided that the Plan does not have to pre-approve TAVR.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayments for the wound care visits provided from September 4, 2019 to September 18, 2019.You asked the Plan to reduce the copayments forthe wound care visits. You say that all of the bills should have a $30 copayment. 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 terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $300 copayment for all other outpatient services not provided in an ambulatory surgical center. For each date of service, you have been asked to pay the allowed amount of the claim because these amounts are less than the $300 copayment for wound care visits in an outpatient hospital.You have been asked to pay a $185.51 copayment for the wound care on each date of service. The wound care visits fall within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The record shows you were billed by the outpatient hospital.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 reduce the copayments forthe wound care visits provided from September 4, 2019 to September 18, 2019
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Lidocaine pads.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 covered.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 Lidocaine pads. Benefits for these services may be available under Medicare Part D.Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for 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 February 21, 2020 with multivessel coronary artery disease with decreased ejection fraction. He underwent an elective coronary artery bypass graft (CABG) with post-op complications of elevated blood pressure and bradycardia. He is now hemodynamically stable. The complexity of his nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. He may benefit from further therapy but 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 enrollee
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an admission for skilled nursing facility (SNF) services.
You asked the Plan to pre-approve the SNF services. You say that you fell and fractured your hip and also had surgery so you will need constant care to rehabilitate. The Plan denied your request. The Plan says you do not meet Medicare criteria for SNF 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 the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your ability to ambulate improved significantly from March 1, 2020 to March 3, 2020. On March 3, 2020 you walked 75 feet x 2 with close supervision. You are able to perform transfers. Our physician reviewer found that the specialized skill, knowledge and judgment of a skilled professional nurse is not required to safely and effectively provide medically necessary and reasonable treatment. While you would likely benefit from continued physical therapy and occupational therapy, skilled nursing or skilled therapy services (or a combination of these services), was not medically necessary on a "daily basis" in a SNF. As a practical matter, you do not require the necessary services on an inpatient basis, in a skilled nursing facility setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve an admission for skilled nursing facility (SNF) services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF admission and services for the enrollee.
You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says the enrollee does not require daily skilled services on an inpatient basis in a SNF.
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 physician reviewer found that the enrollee continues to receive wound care. He requires oversight of his medical conditions and medication management. He has not returned to his prior level of function. He is ambulating greater than household distances and performing essential activities of daily living without hands on assistance. There are skilled needs, but they do not need to be provided 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 skilled nursing facility (SNF) admission and services for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on July 5, 2019 by an out of network provider 
You asked the Plan to pay for the ambulance services. You say that the transport was medically necessary. The Plan denied your request. The Plan says you did not request prior authorization.
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 service 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 ambulance services provided on July 5, 2019 by an out of network provider
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a 156 mile routine transportation trip to an appointment with the doctor.You asked the Plan to pre-approve the 156 mile trip. You say that this is necessary.The Plan denied your request. The Plan says your transportation benefit does not cover trips of this length.Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers routine transportation when each one-way trip does not exceed 50 miles. We looked at your request, the records in the case file, and the rules. The trip requested exceeds the maximum mileage limit. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met.Therefore, we decided that the Plan does not have to pre-approve a 156 mile routine transportation trip to an appointment with the doctor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea Vertiflex interspinous and interlaminar device.You asked the Plan to pre-approvethe Vertiflex interspinous and interlaminar device. You say that the enrollee's physician has furnished a treatment plan with a comprehensive history and physical, medical records, and relevant supporting literature that clearly supports the Superion procedure.The Plan denied your request. The Plan says medical studies have not proven that the requested device is helpful for treatment of the enrollee's health problem.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 Vertiflex interspinous and interlaminar device. Our reviewer says that the requested device is not considered medically reasonable and necessary in this case. Our physician reviewer found the peer reviewed literature is confined to single level placement of an interspinous spacer, and not 2 levels. This device is still considered experimental and investigational due to the lack of a head to head trial with open spinal decompression that is sufficiently powered to prove non-inferiority. The trials show significant re-operation rates.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 Vertiflex interspinous and interlaminar device have not been met.Therefore, we decided that the Plan does not have to pre-approvea Vertiflex interspinous and interlaminar device.