Persius/hicric huggingface dataset:
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approveProlia (J0897).You asked the Plan to pre-approveProlia. You say that this is medically necessary.The Plan denied your request. The Plan says the enrollee has not met the step therapy requirements.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. Our reviewer says that the criteria for coverage of Prolia have not been met. Our physician reviewer found the Plan requires a history of osteoporotic fracture or a trial of zoledronic acid before they will approve the requested drug. The documentation does not show that the enrollee a history of osteoporotic fracture or has tried zoledronic acid. The documentation also does not showthat zoledronic acid would likely be less effective 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 Prolia have not been met.Therefore, we decided that the Plan does not have to pre-approveProlia (J0897).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea Euflexxa injection.You asked the Plan to pre-approvea Euflexxa injection. You say that the requested Euflexxa injection is medically necessary.The Plan denied your request. The Plan says the requested Euflexxa injection is not medically necessary. The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a Euflexxa injection. Our reviewer says that the requested Euflexxa injection is not medically necessary. Our physician reviewer found the enrollee is diagnosed with osteoarthritis.  There is no documentation of adequate conservative measures such as physical therapy for knee pain. More conservative measures are needed. Eufflexa is not medically 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 a Euflexxa injection have not been met.Therefore, we decided that the Plan does not have to pre-approvea Euflexxa injection.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that IRF care is medically reasonable and necessary.The Plan denied your request. The Plan says the enrollee does not meet the requirements for coverage of IRF care.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. There is no reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided 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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveOxycontin tablets.You asked the Plan to pre-approveOxycontin tablets. You say that you would like the Plan to reconsider their denial.The Plan denied your request. The Plan says Oxycontin tablets are not covered under the Medicare Part B benefits.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-approveOxycontin tablets.Benefits for Oxycontin tabletsmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits forfurther information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay forthe self-administered drugs provided from October 8, 2019 to October 9, 2019.You asked the Plan to pay forthese drugs. You say that you were given the medications during your outpatient surgery, and had no control over the medications.The Plan denied your request. The Plan says that 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 pay forthe self-administered drugs provided from October 8, 2019 to October 9, 2019.Benefits for these drugsmay be available under Medicare Part D.Contactthe 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-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that the requested admission to a LTACH is medically necessary.The Plan denied your request. The Plan says the requested admission to a LTACH is not medically necessary.The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested admission to a LTACH is not medically necessary. Our physician reviewer found the enrollee was admitted to an acute inpatient hospital on 2/5 with melena and anemia. The review indicates that the enrollee still requires acute level of care hospital services and is receiving appropriate care at the present acute care hospital. Transfer to a LTACH is not medically necessary at this time. The enrollee is receiving appropriate care at the current acute care facility. Although the enrollee has 2 wound vacs requiring 2-3 x week changes, remaining wound care is not complex requiring skilled nursing of at least 6.5 hours per day, and with the current documentation would not expect need for continued inpatient level of care of at least 25 more days. The review has determined that the enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate forthe diagnosis and condition of 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 LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe visual field test (92083) scanning computerized ophthalmic diagnostic imaging (92133) ophthalmological services (92012) provided October 14, 2019.You asked the Plan to pay forthe vision services. You say that when you got this plan you were told that everything would be taken care of by the plan and there was no deductiblesThe Plandenied your request. The Plan says the claim was correctly applied towards the deductible.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is $183 deductible. Until you have paid the combined deductible amount, you must pay the full cost for covered services from in-network or out-of-network providers. Once you have paid the deductible, the plan will pay their share of costs for these services and you will pay your share (copayment or coinsurance amount) for the rest of the year.The item or service you asked the Plan to pay for falls within the benefit category deductible. The Plan has followed Medicare rules by clearly disclosing in the contract thatthere is $183 deductible. This cost sharing is a contractual obligation that had not been met at the time the vision services was received on October 14, 2019.Therefore, we decided that the Plan does not have to pay forthe visual field test (92083) scanning computerized ophthalmic diagnostic imaging (92133) ophthalmological services (92012) provided October 14, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvenew dentures.You asked the Plan to pre-approvenew dentures. You say that you would like the Plan to reconsider your request.The Plan denied your request. The Plan saysadjustments, relines, rebase and repairs of removable dentures are covered when medically necessary. The Plan states new dentures or replacement dentures are not covered.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 new dentures are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approvenew dentures.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that admission to a LTACH is medically necessary.The Plan denied your request. The Plan says the enrollee is receiving appropriate in-patient acute care and doesnot require transfer to a LTACH.The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrolleeis currently receiving medically necessary acute and/or critical care. The enrolleedoes not have clinical conditions that cannot be appropriately treated in the current hospital, and there are no issues for which the LTACH may offer a therapeutic advantage. The review has determined that the enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient 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 the LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Planhasto pre-approveendovenous ablation therapy of incompetent veins for the enrollee.You asked the Planto pre-approvethe procedure. You say that this is the best treatment for the enrollee.The Plandenied your request. The Plansaysthatthe clinical notes do not specify the use of graduated stockings.The Plan must follow Medicare rules. Medicare rules say that services are covered 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 procedure. Our reviewer says that the requested procedure is considered medically reasonable and necessary in this case. Our physician reviewer found there is documented use of graduated compression stockings, the enrollee's BMI is less than 35, there is documented leg elevation, and the enrollee has an active walking exercise program. She continues to have symptoms and swelling. A Duplex venous study of the involved lower extremity demonstrated patency of the deep venous system, with no DVT.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 procedure have been met.Therefore, we decided that the Planhas to pre-approveendovenous ablation therapy of incompetent veins for the enrollee.If the Plandoes 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/orsend us the new information. This does not happen often. If we decide toopen the case again, we will send you a letter.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran ambulance trip provided on September 5, 2019.You asked the Plan to waive the copayment foran ambulance trip. You say that the ambulance services were necessary and you disagree with the charges.The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $200 copayment for ambulance services. You have been asked to pay a $200 copayment for an ambulance trip. An ambulance trip falls within the ambulance 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 foran ambulance trip provided on September 5, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute IRF admission and services for the enrollee.You asked the Plan to pre-approveIRF care. You say that the enrollee's current needs cannot safely be met at a lower level of care.The Plan denied your request. The Plan says the enrollee does not need an intensive team approach for care, or to be seen by a rehab physician threetimes a week.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 is ambulating using a four wheeled walker with minimal assist, transfers with minimal to contact guard assist, and bed mobility with minimal assist. 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 documentation does not reveal that the enrollee's medical status requires the intensity of an IRF stay with close physician or nursing supervision. The enrollee may benefit and participate in additional physical and occupational therapy, but does not require this on an intensive rehabilitation facility therapy program level 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-approveacute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve transition lenses.You asked the Plan to pre-approve the transition lenses. You say that you have migraines and problems with vision. The Plan denied your request. The Plan says special lenses such as transition lenses are not a Medicare benefit or health plan benefit.The Plan must follow Medicare rules. Medicare rules say thatphotochromatic lenses are covered only when they are medically necessary for the individual beneficiary and the medical necessity is documented by the treating practitioner.Photochromatic lensesused as sunglasses, which are prescribed in addition to regular prosthetic lenses to a pseudophakic beneficiary, will be denied as non-covered.We looked at the file and Medicare rules. The file does not contain medical records from the treating physician to substantiate coverage criteria based on Medicare rules. Therefore, we decided that the Plan does not have to pre-approve transition lenses.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe pneumatic compression pumps (E0666, E0673).You asked the Plan to pay forthe pneumatic compression pumps. You say that the claims should be paid.The Plan denied your request. The Plan says the proof of delivery is not valid for the supplies in this case.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 shows that the Plan made several attempts to obtain the physician order and proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. In instances where the supplies are delivered directly by the supplier, the date the beneficiary received the DMEPOSsupply must be the dates of service on the claim. The enrollee received the supplies on September 5, 2019 which does not match the dates of service associated with the claim.Therefore, we decided that the Plan does not have to pay forthe pneumatic compression pumps (E0666, E0673).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an annual wellness visit (G0439) provided on October 8, 2019.You asked the Plan to pay for the annual wellness visit. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says per Medicare, an annual wellness visit is covered if the member has not received either an initial preventive examination or an annual wellness visit within the past 12 months.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 G0439 is not supported in the record. Specifically, annual visits are covered once every 12 months. The record indicates the member received an annual wellness visit on May 20, 2019. Based on this information, we decided that Medicare rules for coverage of the annual wellness visit have not been met. Therefore, we decided that the Plan does not have to pay for an annual wellness visit (G0439) provided on October 8, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveSNF admission and services for the enrollee.You asked the Plan to pre-approveSNF services. You say that a SNF level ofcare is required to regain strength and ability.The Plan denied your request. The Plan says treatment of generalized deconditioning does not call for skilled therapy.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 performs transfers needed for toileting and out of bed with standby assist and setup. This enrollee does not require skilled nursing or therapy services with the specialized skill, knowledge and judgment of a skilled professional to safely and effectively provide medically necessary and reasonable treatment. The patient does not have complex wound care or other SNF level skilled nursing need. The enrollee does not require these skilled nursing or skilled therapy services (or a combination of these services) on a daily basis. As a practical matter this patient does 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approveskilled nursing facility (SNF) admission and services for the enrollee.