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

We decided that the Plan does not have to pre-approve a lumbar epidural injection.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says in order to qualify for a repeat injection, there must be at least three months relief from the previous injection.

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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found per the review of the medical documentation, you had bilateral L4-L5 and L5-S1 transforaminal epidural steroid injections done on 11/19/20 which provided between 50-60% relief. Per the above Medicare rules, in order to qualify for a repeat injection, you need to have had at least 3 months relief from the previous injection. It has not even been a month since the first injection. Also, Medicare rules state it is not considered medically reasonable and necessary to perform more than 2 epidural injections at a time. Medicare will only allow an injection at a single level on both sides or two injections on the same side of your spine. 

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 a lumbar epidural injection.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).

You asked the Plan to pre-approve admission to a SNF. You say that the requested admission to a SNF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF admission.

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 admission to a SNF. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found based on the documentation provided, the enrollee does not qualify for SNF coverage. The enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. The enrollee is ambulating more than 100 feet and tending to activities of daily living with minimal supervision. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs can be provided at a lower level of 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 admission to a SNF have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the monthly supply allowance for a continuous glucose
monitor (CGM) provided from February 18, 2020, through September 4, 2020.

You asked the Plan to pay for the CGM supply allowance. You say that the diagnosis codes listed on the claim
are supported by the relevant Medicare coverage rules. The Plan denied your request. The Plan says requests
were made for documentation such as the order, proof of delivery, and medical records to support the need for
these supplies. None were received. As such, criteria for coverage are not met.

The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a
physician order and proof of delivery.

The record does not contain a valid physician order, proof of delivery, or relevant medical records which
support the need for these supplies. The record shows that the Plan made several attempts to obtain the
necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the
monthly supply allowance for a continuous glucose monitor (CGM) provided from February 18, 2020, through
September 4, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging (78816).

You asked the Plan to pre-approve the PET scam. You say that you are requesting a appeal for the denial of the authorization due to medical necessity. The Plan denied your request. The Plan says the clinical documentation does not support the requested imaging.

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 the PET scam. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found based on the documentation provided, the health plan's denial should be upheld. There is no evidence that the enrollee is being evaluated for a solid tumor. 

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 PET scam have not been met. Therefore, we decided that the Plan does not have to pre-approve Positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging (78816).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the CT scan chest without contrast (71250).

You asked the Plan to pre-approve the CT scan. You say that based on her aggressive biology and the novel treatment received, the enrollee remains at increased risk of relapse for 5 years after therapy. Therefore, you have recommended 5 years of radiographic surveillance. The Plan denied your request. The Plan says the requested scan is not supported by evidence-based guidelines, nor is there evidence that it is medically necessary.

The Plan must follow Medicare rules. Medicare rules say that CT 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 the CT scan. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found per the NCCN Guidelines surveillance for relapse of DLBCL is every 6 months for 2 years then as clinically indicated. This patient is 4 years from completion of CAR-T cell therapy and on last imaging 7/1/2020 she had no evidence of disease. The service is not reasonable or 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 the CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve the CT scan chest without contrast (71250).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Hurry Cane (E1399).

You asked the Plan to pre-approve this item. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says this item is not a covered benefit under the member's contractual policy or by Medicare as it is an upgraded device that primarily provides comfort or convenience.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose and not be mainly for patient comfort or caregiver convenience.

The item at issue in this appeal has added features beyond what is included in a standard walking cane. These features are considered to be primarily for patient comfort and convenience. As such, this particular type of cane does not meet Medicare criteria for coverage. Therefore, we decided that the Plan does not have to pre-approve a Hurry Cane (E1399).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lumbar spine magnetic resonance imaging (MRI) without contrast.

You asked the Plan to pre-approve the MRI. You say that the medical records provided will show proof of medical necessity. The Plan denied your request. The Plan says the service is not medically necessary for the enrollee's condition.

The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically necessary. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the MRI. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no specific clinical rationale for the requested MRI study. There is no documentation indicating decreased muscle strength or limb circumference. Furthermore, the member's physical exam indicated that his reflexes were normal and there was no mention of sensation or tests regarding straight leg raises or sitting knee extensions. The review has determined that the requested MRI is 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 MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve lumbar spine magnetic resonance imaging (MRI) without contrast.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) services.

You asked the Plan to pre-approve the MRI services. The Plan denied your request. The Plan says the requested imaging is not supported.

The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically necessary. Medicare rules also say that information must be submitted by the supplier or provider to confirm that Medicare coverage criteria have been met. 

We looked at the file and Medicare rules. The only records submitted were the imaging order. There are no records which demonstrate that the requested MRI is medically necessary or allow for our review of medical necessity. The case file shows that the Plan made reasonable attempts to obtain medical records, unsuccessfully. Based on this information, we decided that Medicare rules for coverage of the MRI services have not been met. Therefore, we decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) services.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Prolia injections (J0897).

You asked the Plan to pre-approve Prolia. You say that Prolia is medically necessary. The Plan denied your request. The Plan says that rules for coverage were not met.

The Plan follows Medicare rules. Medicare rules say that Prolia is covered when 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 Prolia. Our reviewer says that Prolia is medically necessary. Our physician reviewer found the review indicates that the enrollee has a history of osteoporosis and prior Alendronate failure. There is a history of fracture and the enrollee has been on Prolia since at least 2018. Coverage criteria has 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 Prolia have been met. Therefore, we decided that the Plan has to pre-approve Prolia injections (J0897).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre Sensor.

You asked the Plan to pre-approve a Freestyle Libre Sensor. You say that the item is necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. 

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a Freestyle Libre Sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre Sensor.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CancerNext, plus RNA insight genetic testing.

You asked the Plan to pre-approve CancerNext, plus RNA insight genetic testing. You say that you would like
the plan to reconsider their denial. The Plan denied your request. The Plan says you do not meet criteria for the
requested services.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed above, are not covered.

The CancerNext, plus RNA insight genetic testing at issue in this appeal is being requested solely for screening
purposes. Review of the file shows that this is a request for a multi-gene panel that tests for 36 genes and 8
cancers. There is no documentation that indicates that you have a hereditary cancer syndrome or that you have
a personal or family history of all cancers evaluated by the test.
Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not
have to pre-approve CancerNext, plus RNA insight genetic testing.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of Actemra via intravenous infusion.

You asked the Plan to pre-approve Actemra. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because the records do not support Actemra via intravenous infusion.

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 Actemra. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested use of Actemra. Our physician reviewer found the intravenous form of Actemra is not Food & Drug Administration (FDA) approved for the enrollee's diagnosis. This use of Actemra is not supported by one of the major drug compendia or by clinical research that appears in a Medicare-approved medical journal. There is no documentation that the intravenous form of Actemra is safe and effective and otherwise reasonable and necessary 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 Actemra have not been met. Therefore, we decided that the Plan does not have to pre-approve use of Actemra via intravenous infusion.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the outpatient mental health services to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve the outpatient mental health services. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are neither emergent nor urgent to seek out-of-network care. The Plan says there are in-network providers available to you that can provide the care you are requesting.

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 the outpatient mental health services to be provided by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that a lower level of care cannot provide the care needed. The Plan denied your request. The Plan says the enrollee does not require an intensive, complex, multidisciplinary approach to daily therapy.

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 was treated in the hospital with orthopedic consultation and underwent surgical repair of the fracture. She is weak and unsteady. She is walking 40 feet with a rolling walker with contact guard assistance and is contact guard assist for transfers and is supervision for some activities of daily living. Her therapy is reported to be limited by decreased endurance and pain. The complexity of the enrollee's nursing, medical and rehab needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. She does require physical and occupational therapy services, but she does not require an intensive inpatient rehabilitation therapy program. 

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.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Botox (J0585).

You asked the Plan to pre-approve Botox. You say that this is medically necessary. The Plan denied your request. The Plan says this use of Botox is not supported.

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 Botox. Our reviewer says that the criteria for coverage of Botox has not been met. Our physician reviewer found the requested use of Botox to treat member's gastroparesis does not constitute a medically accepted indication. 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. 

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 have not been met. Therefore, we decided that the Plan does not have to pre-approve Botox (J0585).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa.

You asked the Plan to pre-approve Euflexxa. You say that you would like this medication because your physician ordered it for you. The Plan denied your request. The Plan says that you have not tried and failed the preferred step therapy drugs.

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 Euflexxa. Our reviewer says that Euflexxa is not medically reasonable and necessary. You have not tried and failed Orthovisc and Monovisc. There is no documentation provided indicating that Orthovisc and Monovisc would likely be less effective and/or likely have adverse effects for you. Our physician reviewer found that your condition does not meet step therapy criteria for Euflexxa. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have to pre-approve Euflexxa.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that the enrollee is able to do 3 hours of therapy a day, and needs frequent physician monitoring. The Plan denied your request. The Plan says the level of intensive therapy exceeds the enrollee's needs.

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 was treated in the hospital with a transfusion of packed red blood cells and fresh frozen plasma. She suffered respiratory failure and required intubation, mechanical ventilation, and antibiotics. Her condition is improved, but she is weak and deconditioned. She is walking about 5 feet with a wheeled walker with stand-by assistance, is minimum assist for most transfers, and maximum assist for some activities of daily living. She is reported to be medically stable for discharge. 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 require physical and occupational therapy services, but does not require an intensive inpatient rehabilitation therapy program. 

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.