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

We decided that the Plan does not have to pre-approve Synvisc injections.
You asked the Plan to pre-approve Synvisc injections. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the requested injections are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA approved
drugs if they are medically accepted as safe and effective or appropriate for the particular use.
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 Synvisc injections. Our reviewer says
that the documentation does not support that the requested Synvisc injections are medically reasonable or
necessary. Our physician reviewer found the enrollee has severe osteoarthritis of bilateral knees. The progress
notes stated that the enrollee's knee pain worsened and did not benefit from the injection on March 29, 2021.
The enrollee was also given a brace to wear at that time. A progress note on April 6, 2021 documented that the
member has not tried using the brace. Therefore, the enrollee does not meet criteria for the requested injections.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Synvisc injections have not been met. Therefore, we decided that the Plan does
not have to pre-approve Synvisc injections.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the outpatient office visit (99202).
You asked the Plan to pre-approve the office visit. You say that you would like to appeal the decision for chiropractic services. You need this service as you have bad back pain. This is very painful, and it hurts to move and get around. The Plan denied your request. The Plan says this service is not covered when rendered 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-approve the outpatient office visit (99202).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Botox injections.
You asked the Plan to pre-approve Botox injections. You say that you believe this should be approved as the injection seems to be the only thing that helps after many years. The Plan denied your request. The Plan says the requested services are not medically necessary.
The Plan follows Medicare rules. Medicare rules say that Botox is only covered for certain indications. 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 Botox injections. Our reviewer says that the documentation does not support that the requested Botox injections are medically reasonable or necessary. Our physician reviewer found you have gastroparesis. Though trials evaluating the effect of intrapyloric botulinum toxin injection on gastroparesis have been reported, there is no agreement whether botulinum toxin can effectively relieve the symptoms and improve the results of gastric emptying study in patients with gastroparesis. Despite its popularity among some provider, the service under review remains controversial and experimental. Therefore, you do not meet criteria for the requested 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 Botox injections have not been met. Therefore, we decided that the Plan does not have to pre-approve Botox injections.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit (99202) to be rendered by the out of network (OON) provider.
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says the are available in-network providers that can render the requested service.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the service at issue in this appeal. We found no exception that would require the Plan to pre-approve this service. Therefore, we decided that the Plan does not have to pre-approve an office visit (99202) to be rendered by the out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve unspecified implant procedure, by report (D6199) x4.
You asked the Plan to pre-approve implants. You say that the implants are medically necessary. The Plan denied your request. The Plan says this service is not covered under your benefits.
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-approve unspecified implant procedure, by report (D6199) x4.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and segmental pneumatic appliance (E0667).
You asked the Plan to pre-approve a pneumatic compression device and appliance. You say that you feel that the enrollee would benefit from this given that he is failing conservative treatment. The Plan denied your request. The Plan says the enrollee does not meet the LCD criteria for an advanced lymphedema pump as there is no failed four-week trial of a basic pneumatic compression device of either E0650 or E0651.
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and segmental pneumatic appliance (E0667).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a clinical crown lengthening (D4249) and biologic materials to aid in soft and osseous tissue regeneration (D4265).
You asked the Plan to pre-approve the clinical crown lengthening and biologic materials. You say that you would like half of the payment for these services to be paid because you have only saved for half. The Plan denied your request. The Plan says these services are not covered under your plan.
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-approve a clinical crown lengthening (D4249) and biologic materials to aid in soft and osseous tissue regeneration (D4265).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core build up (D2950) for teeth # 14, 18, and 19.
You asked the Plan to pre-approve the dental services. You say that the core build up is medically necessary. The Plan denied your request. The Plan says core build up is not listed as 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, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve core build up (D2950) for teeth # 14, 18, and 19.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia (J0897).
You asked the Plan to pre-approve Prolia, Denosumab injection (J0897). You say that you want to treat the enrollee with this drug. The Plan denied your request. The Plan says the enrollee has not tried first and failed zoledronic acid and does not have a history of osteoporosis related fracture.
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, Denosumab injection (J0897). Our reviewer says that the drug is not medically reasonable and necessary. Our physician reviewer found the patient has not tried and failed the required drug. There is no documentation provided indicating that the Plan's required drug would likely be less effective and/or likely have adverse effects for the enrollee. There is no documentation provided indicating the enrollee has a history of an osteoporosis related fracture. 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, Denosumab injection (J0897) have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia (J0897).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (80307, G0481) provided December 28, 2020.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the services billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code 80307, & G0481 is not supported in the medical record. Specifically, the place of service listed on the claim for m(81, laboratory) does not match the place of service detailed in the records (57, outpatient rehab). Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (80307, G0481) provided December 28, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the computed tomography angiography (CTA) scan of the chest and CTA scan of the abdomen and pelvis
You asked the Plan to waive the copayment for CTA scan of the chest and CTA scan of the abdomen and pelvis. You say that you were not aware there would be a cost share for the services you received. The Plan denied your request. The Plan says the cost share has processed correctly at this time.
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 Medicare-covered diagnostic radiology services. You have been asked to pay a $300 copayment for CTA scan of the chest and CTA scan of the abdomen and pelvis. These services fall within the Medicare-covered diagnostic radiology 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 computed tomography angiography (CTA) scan of the chest and CTA scan of the abdomen and pelvis
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 you're undergoing severe pain when you stand upright. 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 you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy services to be provided by an out of network provider.
You asked the Plan to pre-approve physical therapy services. You say that the requested services are a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for out of network care have not been met.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network 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 Plan does not have to pre-approve physical therapy services to be provided by an out of network provider.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Granix.
You asked the Plan to pre-approve Granix. You say that this requested drug 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 Granix. Our reviewer says that the requested drug is not medically reasonable and necessary. Our physician reviewer found the enrollee is a 79-year-old enrollee diagnosed with stage IV colon cancer. The request for treatment with filgrastim has been approved. Based upon the step therapy guidelines, the health plan will approve the preferred product(s), Zarxio. The Plan requires a trial of drug Zarxio before they will approve the requested drug. In this case, the patient has not tried and failed the required drug(s). There is no documentation provided indicating that the Plan's required drug(s) 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 Granix have not been met. Therefore, we decided that the Plan does not have to pre-approve Granix.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Durolane syringe (J7318).
You asked the Plan to pre-approve Durolane, Hyaluronan or derivative, durolane, for intra-articular injection, 1 mg (J7318). You say that you want to treat the enrollee with this drug. The Plan denied your request. The Plan says the enrollee has not tried and failed 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 Durolane, Hyaluronan or derivative, durolane, for intra-articular injection, 1 mg (J7318). Our reviewer says that the drug is not reasonable and medically necessary. Our physician reviewer found the enrollee has not trialed viscosupplemental treatments such as Orthovisc and Monovisc. Step therapy, as outlined by the plan, requires these be trialed first. The documentation does not outline contraindications or reasons these medications were not considered or that the plan's required drugs would likely be less effective and/or likely have adverse effects for the enrollee. Without the support of the documentation, Durolane is not approved, as step criteria have not been met. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Durolane, Hyaluronan or derivative, durolane, for intra-articular injection, 1 mg (J7318) have not been met. Therefore, we decided that the Plan does not have to pre-approve Durolane syringe (J7318).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not meet CMS coverage criteria for an SNF admission. You do not have daily nursing needs and you are declining full participation in therapies and exhibiting self-limiting behaviors. You are at baseline. There is no expectation that you will make any progress without participation with chronic immobility. Hence your needs are custodial and not an admission to an SNF with daily physical therapy (PT) and occupational therapy (OT) and nursing care. Your needs can be addressed with intermittent skilled services such as PT and OT in a long-term care facility. While you may benefit from PT, and OT when you participate but there is no evidence of need for an intensive therapy program with therapy daily in an inpatient setting as in an SNF. Your care can be provided in an alternate setting such as in a long-term care facility and SNF stay is 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for additional routine transportation trips.
You asked the Plan to provide coverage for additional routine transportation trips. You say that you need transport from home to the dialysis facility. The Plan denied your request. The Plan says your benefit does not cover more than 10 one-way routine trips per Plan year.
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. We looked at your request, the records in the case file, and the rules. The file shows that the Plan only covers up to 10 one-way routine transportation trips per Plan year. Therefore, we decided that the Plan does not have to provide coverage for additional routine transportation trips.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Budesonide Tablet.
You asked the Plan to pre-approve Budesonide Tablet. You say that you want to treat the enrollee with this drug. The Plan denied your request. The Plan says this drug is not covered under the enrollee's Medicare Part B drug 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 Budesonide Tablet.
Benefits for Budesonide Tablet 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 the bone replacement graft for ridge preservation (D7953).
You asked the Plan to pre-approve the bone replacement graft for ridge preservation. You say that without the bone graft your denture will not properly fit. The Plan denied your request. The Plan says the requested service is not covered under your supplemental benefit.
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-approve the bone replacement graft for ridge preservation (D7953).