Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a complete lower denture (D5120).
You asked the Plan to pre-approve the dental items. You say that you need lower dentures. The Plan denied your request. The Plan says that there is no record that you signed up for the optional comprehensive dental benefit. The Plan also says dentures are not listed as covered dental items.
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 complete upper denture (D5110) and a complete lower denture (D5120).
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment with Ilumya (J3245).

You asked the Plan to pre-approve Ilumya. You say that the requested drug is easier for the enrollee than injections at home with the Plan's preferred drugs. The Plan denied your request. The Plan says step therapy criteria have not been met.

Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Ilumya. Our reviewer says that the requested treatment is not medically necessary. Our physician reviewer found that the enrollee has a diagnosis of psoriasis, unspecified. The Plan requires a trial of drugs Enbrel, Humira, and Skyrizi before they will approve the requested drug. The enrollee has not tried and failed the required drugs. The documentation does not support that Enbrel, Humira, and/or Skyrizi 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 Ilumya have not been met. Therefore, we decided that the Plan does not have to pre-approve treatment with Ilumya (J3245).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvesclerotherapy (36465, 36466, 93971, 99214).You asked the Plan to pre-approvesclerotherapy. You say that this service is medically necessary.The Plan denied your request. The Plan says you have not had 3-month trial of conservative therapy.The Plan follows Medicare rules. Medicare rules say that before sclerotherapy is subject to the criteria listed in the Medicare rules section.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 sclerotherapy. Our reviewer says that the requested procedure is not medically necessary and reasonable. Our physician reviewer found while you do have evidence of varicose vein of the left lower extremity with reflux in the accessory saphenous veins, as well satisfactory documentation of pedal pulses, there is insufficient documentation that conservative efforts have been trialed and failed. Additionally, thereis insufficient documentation that you are having lifestyle or mobility limiting symptoms including documentation that such symptoms persist despite the regular use of compression stockings.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of sclerotherapy have not been met.Therefore, we decided that the Plan does not have to pre-approvesclerotherapy (36465, 36466, 93971, 99214).
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 would benefit from acute inpatient rehab to upgrade his function. 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 in the Medicare rules section. 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 admitted to the acute care hospital for altered mental status and encephalopathy. His medical problems are stable. There are no complex nursing needs. The enrollee does not require treatment by multiple therapies, including either physical or occupational therapy, in an intensive rehab 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for urgently needed services provided on December 26, 2020.
You asked the Plan to waive the copayment for the urgently needed services. You say that you are appealing your cost-share responsibility for the services you received. The Plan denied your request. The Plan says the claim was processed accordingly with your 2020 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received urgently needed services provided on December 26, 2020. The Medicare-allowed amount for the urgently needed services is less than the set $65 copayment; therefore, you have been asked to pay the lesser amount of $56.38 for the services. Your 2020 EOC says that enrollees must pay a $65 copay per visit for Medicare-covered urgently needed services. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for urgently needed services provided on December 26, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee would be equally well-served at an alternate level of care.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria for 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 the admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acupuncture, one or more needles, with electrical stimulation (97781).
You asked the Plan to pre-approve acupuncture services. You say that the enrollee was recently hospitalized for abdominal pain and was seen by GI and it was recommended she receive acupuncture. Please cover acupuncture for the enrollee as it is medically necessary. The Plan denied your request. The Plan says the request for acupuncture is not medically necessary for this enrollee.
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the Plan's rules apply in this case. We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Specifically, the request for acupuncture is not medically necessary for this enrollee. Therefore, we decided that the Plan does not have to pre-approve acupuncture, one or more needles, with electrical stimulation (97781).
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 services are 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. 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 there are no services the enrollee requires that he cannot receive at the current facility. The elements of the coverage rule are not satisfied. The requested service cannot be recommended. 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the eye exam provided on December 15, 2020.
You asked the Plan to waive the deductible for the eye exam. You say that the service should be covered in full. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing amount.
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 a $500 deductible that applies towards out-of-network eye exams. The eye exam you asked the Plan to waive the deductible for falls within the "Vision care" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $500 deductible that applies towards out-of-network eye exams. This cost sharing is a contractual obligation that had not been met at the time the eye exam was received on December 15, 2020. Therefore, we decided that the Plan does not have to waive the deductible for the eye exam provided, on December 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ondansetron 4mg oral tablet 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 this is a Part D drug, and there is no Part D 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 Ondansetron 4mg oral tablet for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an advanced foot feature for a prosthetic leg.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says a request for a replacement K3 foot does not meet Medicare criteria as reasonable and necessary.
The Plan must follow Medicare rules. Medicare rules say that an advanced foot feature is covered when the enrollee is functional level K3 or higher.
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 based on the medical records of the prescribing physician that have been provided there is no documentation that the enrollee is a K3 ambulator to indicate this prosthetic advanced foot feature. A procedure note of 02/17/2021 reports the enrollee is a non-ambulator; other provided records of 03/11/2021 do not support that he is a K3 ambulator. 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. The advanced foot feature is not considered necessary for someone who is not a K3 ambulator. Additionally, L5620, L5629, L5645, L5704, and L5647 cannot be covered as prosthetic additions. Therefore, we decided that the Plan does not have to pre-approve an advanced foot feature for a prosthetic leg.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia
You asked the Plan to pre-approve Prolia. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug does not meet step therapy criteria.
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 documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer found the enrollee has osteoporosis without current pathological fracture, diagnosis confirmed with bone density testing. The enrollee cannot tolerate oral bisphosphonates due to gastroesophageal reflux disease. The documentation does not support that the enrollee has tried and failed zoledronic acid. The documentation does not support that the plan required drug would be less effective and/or likely have adverse effects for the enrollee.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia
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 you disagree with the denial. The Plan denied your request. The Plan says the services are 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 LTACH care is not medically necessary. Our physician reviewer found the enrollee was admitted to the hospital with shortness of breath and valvular heart disease. She is receiving acute care services and acute care services are not being denied at the current facility. She does not require services at the LTACH that are not currently being provided. The LTACH services are 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 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral for an office visit and a nervous system procedure.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says this is being requested at an office that uses chiropractors, not physicians, in using "bio-electric therapy."

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. 

The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pre-approve a referral for an office visit and a nervous system procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a tooth extraction (D7140).

You asked the Plan to pre-approve the tooth extraction. You say that you would like reconsideration because your tooth is cracked all the way through, and you are taking nerve medicine 8 times per day to deal with the pain. The Plan denied your request. The Plan says this service is considered non-covered per your dental benefit plan.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a tooth extraction (D7140).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (D2740) for tooth #4.

You asked the Plan to pre-approve the crown. You say that the existing filling on tooth #4 came out, and now
needs a full coverage restoration. You also say that tooth #4 is an anchor tooth for the enrollee's upper denture,
which is another reason this tooth needs a crown. The Plan denied your request. The Plan says the tooth does
not appear to have significant breakdown due to decay or trauma.

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. The Plan covers the crown
when the services are medically necessary and reasonable.

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 crown. Our reviewer says that given
the presentation of the tooth, there would be no medical necessity for a crown on tooth #4. Our physician
reviewer found the Plan requires that for a crown restoration to be considered on a premolar tooth that three or
more surfaces and at least one cusp be compromised. Our reviewer found that in this instance there are two
involved surfaces but no cuspal involvement. Our physician reviewer also found that the amount of damaged or
missing structure is insufficient to consider this tooth for a crown restoration, and the tooth can readily be
restored with a conventional restoration.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
the Plan's rules for coverage of the crown have not been met. Therefore, we decided that the Plan does not have
to pre-approve a crown (D2740) for tooth #4.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveinpatient hospital care for the elective right total shoulder arthroplasty (CPTcode 23472).You asked the Plan to pre-approveacute inpatient hospital care. You say that you are in pain and you feel the inpatient admission is medically necessary.The Plan denied your request. The Plan says the services are not necessary.The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. The planned procedure listed under CPT code 23472 is not listed on the CMS Inpatient Only List. The procedure is currently approved as an ambulatory procedure. There is no documentation provided to support the expectation you will require a greater than two (2) midnightstay. If you experience any peri-or post-operative complications, reconsideration for inpatient level of care can be performed on concurrent review with updated clinical information.Therefore, we decided that the Plan does not have to pre-approveinpatient hospital care for the elective right total shoulder arthroplasty (CPT code 23472).
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 the IRF services are medically necessary. The Plan denied your request. The Plan says coverage criteria has not been 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 in the Medicare rules section. 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 enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. 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.