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

We decided that the Plandoes not haveto pre-approveAranesp injection for the enrollee.You asked the Planto pre-approvethe drug. You say that this is medically necessary.The Plandenied your request. The Plansaysthere is no evidence of a trial and failure of Retacrit.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 injection is not medically reasonable or necessary. Our physician reviewer found there is no evidence of a trial and failure of Retacrit. The documentation does not support that Retacrit would likely be less effective, and/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 the drug have not been met.Therefore, we decided that the Plandoes not haveto pre-approveAranesp injection for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveOfev capsules.You asked the Plan to pre-approveself-administered drugs. You say that you are appealing with records.The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because this drug is not covered by Medicare Part B and the Plan does not administer the enrollee's Medicare Part D prescription drug 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-approveOfev capsules.Benefits for self-administered 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvefoot orthotics.You asked the Plan to pre-approvefoot orthotics (L3310). You say that because of yourfoot condition you needa special shoe and not a brace.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-approvefoot orthotics.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea bathtub wall rail.You asked the Planto pre-approvethe wall rail. You say that this is medically necessary.The Plandenied your request. The Plansaysthis is not a covered benefit.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured.Therefore, we decided that the Plandoes not haveto pre-approvea bathtub wall rail for the enrollee
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve13 outpatient physical therapy visits to be provided by the out of network provider.You asked the Plan to pre-approve the outpatient physical therapy visits. You say that you with to use this provider to further your rehabilitation process. You also say that you are aware there are many facilities in the network, but this is the one you want to use.The Plan denied your request. The Plan says the requested services can be provided within the Plan's network.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 pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has confirmed there are 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 13 outpatient physical therapy visits to be provided by the out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an occlusal guard (code D9944).You asked the Plan to pre-approve the occlusal guard. You say that the services are medically necessary.The Plan denied your request. The Plan says this service is not a covered 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 an occlusal guard (code D9944).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe medical services to be provided by out of network provider, "the doctor".You asked the Plan to pre-approvea virtual colonoscopy. You say that you would like a virtual diagnostic colonoscopy because it is less invasive.The Plan denied your request. The Plan says the standard of care is a traditional colonoscopy. The Plan says that they did need receive information to support the medical necessity for a diagnostic virtual colonoscopy.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 pre-approved care.The requested provider in this case is not a networkprovider with the Plan. 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-approvethe medical services to be provided by out of network provider, "the doctor".
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an incisional biopsy of oral tissue - soft (code D7286) and removal of benign nonodontogenic cyst or tumor (code D7461).
You asked the Plan to pre-approve the incisional biopsy of oral tissue and removal of benign nonodontogenic cyst or tumor. You say that you enrolled with the plans because they told you they would pay for your dentures. You also say that you have 20 year old dentures and were told not to wear them because they are destroying the top of your mouth. The Plan denied your request. The Plan says these services are not covered supplemental 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 an incisional biopsy of oral tissue - soft (code D7286) and removal of benign nonodontogenic cyst or tumor (code D7461).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Cosentyx for the enrollee. You asked the Plan to pre-approve Cosentyx. You say that the enrollee has tried and failed other drugs.The Plan denied your request. The Plan says the enrollee's medical plan does not cover outpatient prescription drugs.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-approveCosentyx for the enrollee .Benefits for Cosentyx may be available under Medicare Part D.Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH admission at the in-network benefit level.
You asked the Plan to pre-approve LTACH admission at the in-network benefit level. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the Plan has approved the admission for LTACH services at the enrollee's Point of Service benefit.
The Plan must follow Medicare rules. The rules say that a Medicare Health Plan must disclose to its members the benefits offered under the plan including applicable conditions and limitations, premiums and cost sharing such as copayments, deductibles and coinsurance. We looked at the file, the Plan's contract and Medicare rules. The Plan has approved admission to the requested out-of-network LTACH for the enrollee. The plan's contract with the enrollee clearly states the enrollee has a Point of Service benefit that allows the enrollee to use out-of-network providers. The Plan states there are in-network facilities available to the enrollee if the enrollee would like to use the in-network benefit for the approved LTACH admission. Based on this information, we decided that Medicare rules for coverage of LTACH admission at the in-network benefit level have not been met. Therefore, we decided that the Plan does not have to pre-approve LTACH admission at the in-network benefit level.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gel-One knee injections.You asked the Plan to pre-approve the requested services. You say that you are afraid of falling, and putting too much weight on the leg.The Plan denied your request. The Plan says you have not had previous treatment, 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 the requested services. Our physician reviewer found that you have pain related to osteoarthritis of the left knee, confirmed with x-rays. You have failed conservative treatment. The Plan requires a trial of drugs Orthovisc and Monovisc first before they will approve the requested drug. The provided medical records do not indicate that you have tried and failed the required drugs. The medical records do not indicate that the Plan's required drugs would likely be less effective, or likely have adverse effects.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 requested services have not been met.Therefore, we decided that the Plan does not have to pre-approve Gel-One knee injections.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 8 additional visits/Ozurdex injections for the enrollee.
You asked the Plan to pre-approve 8 additional visits/Ozurdex injections. You say that the requested 8 additional visits/Ozurdex injections are medically necessary. The Plan denied your request. The Plan says the requested 8 additional visits/Ozurdex injections are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve 8 additional visits/Ozurdex injections. Our reviewer says that the requested 8 additional visits/Ozurdex injections are not medically necessary. Our physician reviewer found the enrollee is with a diagnosis of Type 2 diabetes mellitus with moderate non-proliferative diabetic retinopathy with macular edema, bilateral. The disease process has been progressing despite treatment with Avastin. The prescribing physician requested 24 visits (12 visits per eye). The plan approved 4 visits (2 visits per eye). The requested treatment date span is 01/05/2020 through 01/05/2021. The recommended dose of Ozurdex is one implant administered intra-vitreally to one affected eye at a time. Retreatment may be performed after approximately 6 months if the patient experiences decreased vision and/or an increase in retinal thickness, secondary to recurrent or worsening diabetic macular edema. The efficacy of Ozurdex for the treatment of diabetic macular edema was assessed in two, multicenter, masked, randomized, sham-controlled studies. Subjects were to be evaluated for retreatment eligibility every three months starting from month 6 but could only receive successive treatments at least 6 months apart. Retreatment was based on physician's discretion after examination including Optical Coherence Tomography. The documentation in the case file does not sufficiently support the need for the additional Ozurdex injections 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 8 additional visits/Ozurdex injections have not been met. Therefore, we decided that the Plan does not have to pre-approve 8 additional visits/Ozurdex injections for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.You asked the Plan to pre-approve the SNF services. You say that the enrollee is in the hospital and needs to go to rehab in order to return to her normal independent lifestyle and prior level of function.The Plan denied your request. The Plan says the guidelines for coverage have not been met. The plan says that the enrollee can receive the care needed in another setting, such as home, a long-term care facility, or other outpatient setting.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral medications, had stable vital signs, was treated for pain with effect, and tolerated her TLSO. Our physician reviewer found that the enrollee's wound VAC was discontinued. Our physician reviewer found that the enrollee received occupational therapy in the acute hospital. Our physician reviewer found that the enrollee was contact guard assist level with functional mobility. Our physician reviewer found that the enrollee required varying assist with activities of daily living. Our physician reviewer found that there are not identifiable skilled nursing service needs. Our physician reviewer found that, while there are identifiable skilled therapy service needs, they are not required on a daily basis. Our physician reviewer found that the enrollee does not meet the severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional mileage for your routine transportation.You asked the Plan to pre-approve additional miles. You say that you can not drive at night, or in poor visibility weather. The Plan denied your request. The Plan says your benefit only allows 50 miles. Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The file shows that you requested transportation for over 50 miles. We looked at your request, the records in the case file, and the rules. Your plan only covers trip for up to 50 miles each way. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to pre-approve additional mileage for your routine transportation.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Zolpidem Tartrate.You asked the Plan to pre-approve the requested drug. The Plan denied your request. The Plan says drug coverage is limited to Part B covered drugs.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 Zolpidem Tartrate.Benefits for the requested drug may be available under Medicare Part D.Contac tthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is in need of continued ventilator management and wean with continued hemodialysis for acute chronic renal failure. The appellant says that the enrollee need daily lab monitoring and telemetry with physical therapy. The Plan denied your request. The Plan says the enrollee's needs are currently being met in the acute setting and an LTACH would add no additional services. The plan says that, with additional time in the current setting and with clinical stability, the enrollee could be transitioned to a lower level of care.
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 the enrollee is currently undergoing treatment at an acute care hospital (ACH) for respiratory failure and aspiration following vascular surgery. Our physician reviewer found that the enrollee was intubated/ventilated and subsequently received a tracheotomy and feeding tube. Our physician reviewer found that the enrollee's long-term prognosis and goals are unclear. Our physician reviewer found that there is no advantage in transferring the enrollee to the LTACH. Our physician reviewer found that the enrollee can remain at the current ACH until such time that no acute services are required and can then be transferred/discharged to a lower level of care for any ongoing long term care needs. 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-approve long term acute care hospital (LTACH) services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Zilretta injection (J3304, 20610).You asked the Plan to pre-approve a Zilretta injection. You say that the requested medication is necessary.The Plan denied your request. The Plan says there is no evidence from long-term studies showing benefits over traditional steroid injections. Therefore, coverage criteria has not been met.The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a Zilretta injection. Our reviewer says that the medication is not medically necessary. Our physician reviewer found Zilretta is FDA-approved for intra-articular injection of the knee for osteoarthritis but review of available literature on Zilretta does not show any statistically significant long term benefit of Zilretta over traditional immediate-release formulations of triamcinolone for intra-articular injection of the knee for osteoarthritis pain.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 Zilretta injection have not been met.Therefore, we decided that the Plan does not have to pre-approve a Zilretta injection (J3304, 20610).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a right knee genicular nerve block (64640). You asked the Plan to pre-approve a right knee genicular nerve block. You say that other treatments have not been effective for the enrollee.The Plan denied your request. The Plan says this is not medically necessary for the enrollee's condition.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 right knee genicular nerve block. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found current evidence based medical literature do not support the use of genicular nerve block as safe and effective as a treatment for chronic knee osteoarthritis pain at this time. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of these procedures for this patient as discussed above. Therefore, this request for right genicular nerve block is not medically reasonable and necessary for treatment of this enrollee's medical condition.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 right knee genicular nerve block have not been met.Therefore, we decided that the Plan does not have to pre-approve a right knee genicular nerve block (64640).