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

We decided that the Plan has to pre-approve skilled nursing facility (SNF) care for the enrollee.
You asked the Plan to pre-approve SNF care. You say that SNF admission is medically necessary. The Plan denied your request. The Plan says that Medicare coverage criteria are 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 pre-approve SNF care. Our reviewer says that Medicare coverage criteria are met. Our physician reviewer found the documentation supports that skilled therapy services on a daily basis are medically reasonable and necessary 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 SNF care have been met. The Plan must continue coverage for the SNF skilled service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing facility (SNF) care for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a sacroiliac joint injection for the enrollee.
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your
request. The Plan says it has not been proven that the pain is coming from the sacroiliac joint.
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 injection. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found diagnostic lateral sacral blocks do not have proven efficacy in treating SI joint pain. Rather, they would
be part of the diagnostic work-up before RFA of the lateral sacral branches. RFA of the lateral sacral branches
is considered experimental/ investigational because of the wide variation in efficacy reported in the peer
reviewed literature. Therefore, the request is considered 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 injection have not been met. Therefore, we decided that the Plan does not
have to pre-approve a sacroiliac joint injection for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveFebuxostat tablet.You asked the Plan to pre-approveFebuxostattablet. You say that you want the enrollee treated with this drug.The Plan denied your request. The Plan says this drug is not covered under the enrollee's Medicare Part B 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-approveFebuxostat tablet.Benefits for Febuxostat tabletmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveGelsyn-3.You asked the Plan to pre-approveGelsyn-3. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested drug is not medically necessary.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 Gelsyn-3. Our reviewer says that the documentation does not support that the requested drug is medically reasonable or necessary. Our physician reviewer found the enrollee has a diagnosis of left knee pain, unspecified. The documentation does not support that the enrollee has tried and failed Orthovisc and Monovisc. The documentation does not support that Orthovisc and Monovisc would likely be less effective and/or likely have adverse effects for the enrollee. Therefore, the enrollee does not meet criteria for the requested drug.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bone graft for ridge preservation (D7953), guided
tissue regeneration (D4266), gingival irrigation (D4921 x 4), and core build up (D2950).
You asked the Plan to pre-approve the dental services. You say that the dental services are medically necessary.
The Plan denied your request. The Plan says bone graft for ridge preservation is not listed as a covered service.
The Plan says guided tissue regeneration is not listed as a covered service. The Plan says that gingival irrigation
is not listed as a covered service. The Plan also says that 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 a
bone graft for ridge preservation (D7953), guided tissue regeneration (D4266), gingival irrigation (D4921 x 4),
and core build up (D2950).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia 60mg/ml syringe for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says step therapy encourages a trial of zoledronic acid, which is just as effective.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found it is noted that recent bone mineral density T-score was -2.0, and that the request for Prolia was a new start at the time of a patient encounter on November 10, 2020. The plan's coverage criteria require failure of, or intolerance/contraindication to Zoledronic acid, or history of an osteoporotic fracture. The prescriber has indicated 1) that the enrollee has not had an osteoporotic fracture, and 2) that the enrollee has not tried Zoledronic acid nor does she have a contraindication to Zoledronic acid. Additionally, the prescriber has not indicated that Zoledronic acid would be less effective than the requested drug and/or would have adverse effects for the enrollee. In summary, neither step therapy or step therapy exception criteria are 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 the drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia 60mg/ml syringe for the enrollee.
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.
You asked the Plan to pre-approve IRF care. You say that IRF admission is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met.
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 current nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for a pulmonary embolism then discharged to a skilled nursing facility. You were discharged to home, where you currently reside. There are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. Medicare coverage criteria are not 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 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveskilled nursing facility (SNF) admission.You asked the Plan to pre-approveSNF care. You say that SNF care is medically necessary.The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the patient does not require skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis" in a SNF. As a practical matter, this patient doesnot 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 care have not been met.Therefore, we decided that the Plan does not have to pre-approveskilled nursing facility (SNF) admission
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bilateral SI joint injections (27096).
You asked the Plan to pre-approve bilateral SI joint injections (27096). You say that the requested bilateral SI
joint injection (27096) is medically necessary. The Plan denied your request. The Plan says the requested
bilateral SI joint injection (27096) 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 bilateral SI joint injections (27096).
Our reviewer says that the requested bilateral SI joint injection (27096) is not medically necessary. Our
physician reviewer found the enrollee has a diagnosis of low back pain and neck pain. The most recent
provided office note is dated 12/22/2020. The medical record documents the following positive tests: Fortin
Finger Test, FABER (Patrick's) Test, AP compression test, Gaenslen's test, and pelvic rock test. The medical
record also documents that the date of onset of the sacroiliac joint pain was 12/4/2020. During previous office
visits, the enrollee has received greater occipital nerve blocks, and C7-T1 epidural steroid injections with
improvement in headaches and neck pain.
The documented date of onset of sacroiliac joint pain is 12/4/2020. Medical records do not document an
adequate trial of conservative therapy for sacroiliac joint pain. The provided medical records do not document
that the enrollee has satisfied the above requirements. Therefore, this procedure is not medically necessary and
reasonable.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of bilateral SI joint injections (27096) have not been met. Therefore, we decided
that the Plan does not have to pre-approve bilateral SI joint injections (27096).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve COSENTYX pens.
You asked the Plan to pre-approve COSENTYX pens. You say that your symptoms have been well-controlled
on this medication. The Plan denied your request. The Plan says coverage of this medication is the
responsibility of your prescription drug plan.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 COSENTYX pens.
Benefits for COSENTYX pens 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveDurolane.You asked the Plan to pre-approveDurolane (J7318). You say that you want the enrollee treated with this drug.The Plan denied your request. The Plan says the enrollee has not first tried and had a contraindication or intolerance to Orthovisc and Monovisc.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 (J7318). Our reviewer says that the drug is not reasonable or medically necessary. Our physician reviewer found the medical record also documents that the enrollee was treated with bilateral Monovisc injections on October 16, 2019, and May 10, 2020; however,the medical record does not specifically state whether the enrollee responded at all to Monovisc. The plan requires trial of, or contraindication to both Monovisc and Orthovisc before they will approve Durolane.  There is insufficient documentation that theenrollee meets the plan's step therapy criteria or thatthe plan's preferred drugs would be less effective than the requested drug and/or would have adverse effects for the enrollee.  As such, an exception to the plan's step therapy criteria is not warranted.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 (J7318) have not been met.Therefore, we decided that the Plan does not have to pre-approveDurolane.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveskilled nursing facility (SNF) services.You asked the Plan to pre-approveSNF services. You say that SNF services are medically necessary.The Plan denied your request. The Plan says Medicare coverage criteria are 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 pre-approve SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled nursing services with  the specialized skill, knowledge and judgment of a skilled professional nurse required to safely and effectively provide medically necessary and reasonable treatment in a SNF beyond the last covered dates.  The enrollee does not have complex wound care or other ongoing SNF level SN need. The enrollee's functional level  does not require  skilled therapyservices with the specialized skill, knowledge and judgment of a qualified therapist  to safely and effectively provide medically necessary and reasonable treatment in a SNF beyond the last covered date. The enrollee does not require ongoing skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis" in a SNF. As a practical matter, this enrollee does not require the necessary services on an inpatient basis, in a skilled nursing facility setting beyond the last covered date. 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) services
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health care.

You asked the Plan to pre-approve home health care. You say that home health care is medically necessary.The Plan denied your request. The Plan says Medicare coverage criteria are not met.

The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.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 home health care. Our reviewer says that Medicare coverage criteria are not met. Our physician reviewer found the records do not show that skilled nursing services are required to effectively provide treatment, care, and/or services in order to improve the current condition, or to establish/perform a maintenance program to maintain the current condition and/or prevent deterioration.  There are no complex wounds, new enteral feedings or other skilled needs. The records do not show that skilled therapy is needed to effectively provide treatment, care, and/or services in order to improve the current level of function, or to establish/perform a maintenance program to maintain the current level of function and/or prevent deterioration. Medicare coverage criteria are not 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 home health care have not been met.Therefore, we decided that the Plan does not have to pre-approve home health care
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea shower chair.You asked the Planto pre-approvea shower chair. You say that you have excruciating back pain due to spinal stenosis.The Plandenied your request. The Plansaysthis does not serve a primarily medical purpose.The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item.Therefore, we decided that the Plandoes not haveto pre-approvea shower chair
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve multaq 400 mg tablet.
You asked the Plan to pre-approve multaq 400 mg tablet. You say that the item is medically necessary. The Plan denied your request. The Plan says this drug is not covered for the enrollee's condition. The enrollee has Part A and Part B coverage, with no Part D drug coverage.
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 multaq 400 mg tablet.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveSynvisc-One syringe for the enrollee.You asked the Planto pre-approvethe syringe. You say that this is medically necessary.The Plandenied your request. The Plansaysstep therapy guidelines were not followed.Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the syringe. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found there is no evidence of a trial and failure of Orthovisc and Monovisc. The plan's required drugs would not likely be less effective and/or likely to have adverse effects for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Desvenlafax.

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 Desvenlafax.

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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve BRCA testing.
You asked the Plan to pre-approve the testing. You say that this is medically necessary. The Plan denied your
request. The Plan says there is no personal history of cancer.
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 test at issue in this appeal, the testing, is being requested solely for screening purposes. Medicare does not
cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pre-approve
BRCA testing.