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

We decided that the Plan does not have to pre-approve Prolia, 60 mg/ml syringe.
You asked the Plan to pre-approve Prolia. You say that the enrollee has gastrointestinal contraindication to the
use of oral bisphosphonates. You also say that this was not included in the initial review. The Plan denied your
request. The Plan says the enrollee has not tried and failed the preferred drugs. The Plan also says that there
was no documentation showing that the enrollee is taking 1000 mg of calcium and 400 IU of vitamin D daily.
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 Prolia is not medically necessary. Our physician reviewer found the provided documentation does not indicate that the enrollee has not tried and failed the required drugs. The reviewer found that there is concern about the safety of oral bisphosphonate therapy due to the esophageal stricture. The reviewer found that there is no indication that zoledronic acid would likely be less effective and/or likely have adverse effects for the enrollee. Therefore, the reviewer found that the criteria for step therapy has not been met.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to
pre-approve Prolia, 60 mg/ml syringe.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve percutaneous laminotomy/laminectomy (interlaminar approach) for decompression of neural elements, (with or without ligamentous resection, discectomy, facetectomy and/or foraminotomy), any method, under indirect image guidance (eg, fluoroscopic, CT), single or multiple levels, unilateral or bilateral; lumbar (CPT code 0275T), for the enrollee.
You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan denied your request. The Plan says medical studies have not proven that the service(s) or procedure(s) is helpful for treatment for the enrollee's health problem.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found detailed documentation is not evident regarding trial and failure of recent, reasonable and comprehensive less invasive conservative care measures. The enrollee had an epidural injection in 2019. No exams are noted/evident between that time and the follow up on May 3, 2021. Furthermore, there is limited published, large-scale, long-term peer-reviewed literature that shows the request to be an effective and/or safe treatment for the noted pathology. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the request for is not medically reasonable or necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pre-approve percutaneous laminotomy/laminectomy (interlaminar approach) for decompression of neural elements, (with or without ligamentous resection, discectomy, facetectomy and/or foraminotomy), any method, under indirect image guidance (eg, fluoroscopic, CT), single or multiple levels, unilateral or bilateral; lumbar (CPT code 0275T), for the enrollee.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Yutiq .01MG injection (CPT code J7314), for the enrollee.
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied your request. The Plan says that the off-label use of this drug for the enrollee's condition is not medically accepted per Medicare rules and is not covered based on available information.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the medication. Our physician reviewer found based on the medical records provided and the Medicare-approved major drug compendia there is documentation that Yutiq 0.18 mg injection is Food and Drug Administration-approved for the enrollee's diagnosis of disseminated chorioretinal inflammation which is synonymous with (posterior) uveitis. Based on the medical records provided and the Medicare-approved major drug compendia there is documentation that the requested drug is safe and effective and otherwise reasonable and necessary for this enrollee's uveitis. 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 medication have been met. Therefore, we decided that the Plan has to pre-approve Yutiq .01MG injection (CPT code J7314), for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve proton beam therapy treatment.
You asked the Plan to pre-approve the requested services. You say that the enrollee meets all the criteria for the requested services. The Plan denied your request. The Plan says the use of proton beam therapy for the treatment of uterine cancer is not the standard of care.
The Plan follows Medicare rules. Medicare rules say that proton beam therapy is only covered under certain medical indications. 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 the case records did not adequately demonstrate the need for proton therapy using dosimetric evidence. This is important in justifying the need for proton therapy in clinical scenarios (such as this case) for which proton therapy is not standard. Simply stating that proton therapy will reduce the dose to some normal tissues does not constitute sufficient documentation for medical necessity of proton therapy, as the reductions should be clinically meaningful, and reduce toxicity risks in a clinically meaningful manner. There is no documentation that a conventional 3D conformal plan or IMRT was (or would be) unacceptable. 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 proton beam therapy treatment.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete upper denture (D5110) and complete lower denture (D5120).

You asked the Plan to pre-approve the dentures. You say that this provider is part of the dental network, and your provider told you that they accept your insurance. The Plan denied your request. The Plan says the provider in question is not part of the dental Plan's network, and therefore these services cannot be 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 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 complete lower denture (D5120).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia Injection.

You asked the Plan to pre-approve Prolia Injection, denosumab, 1 mg (J0897). You say that you want the enrollee to be treated with this drug. The Plan denied your request. The Plan says the enrollee has not first tried and had an adverse reaction to zoledronic acid or has a history of osteoporosis- related fracture.

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 Injection, denosumab, 1 mg (J0897). Our reviewer says that the drug is not medically reasonable or necessary. Our physician reviewer found there is no evidence that the enrollee is allergic to or has been intolerant of these other forms of medication. There is no evidence that the enrollee has tried and not responded to these other forms of medication. There is no documentation as to why these other forms of medication would not be expected to be safe and effective for the enrollee. Therefore, the requested Prolia is not shown to be currently 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 Prolia Injection, denosumab, 1 mg (J0897) have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia Injection.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve six (6) office consultations and treatment to be performed by an out-of-network provider.

You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your request. The Plan says the services are not necessary.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.

The provider at issue in this case is not a network provider with the Plan. 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 physician reviewer found based on the provided documentation, the enrollee could have foreseen requiring the services prior to leaving the service area. Follow-up with a podiatrist was reasonable and medically necessary to treat his ulcer and Charcot deformity. It would have been reasonable to delay the services until the enrollee was able to see a more local in-network podiatrist as there was no urgency with the care provided. 

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 Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve the services. Therefore, we decided that the Plan does not have to pre-approve six (6) office consultations and treatment to be performed by an out-of-network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an intracept procedure.

You asked the Plan to pre-approve the requested services. You say that study results clearly demonstrate long-term effectiveness and the durability of ablating the basivertebral nerve. The Plan denied your request. The Plan says there are not enough studies to show the intracept is safe and effective to treat back pain.

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 requested services. Our physician reviewer found that the intracept procedure remains experimental for the treatment of low back pain. More research is needed to clearly show the safety and efficacy of the procedure. Therefore, the requested services are 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 requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve an intracept procedure.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve computed tomography (CT) thorax (71250).
You asked the Plan to pre-approve the CT scan. You say that the medical records should support the medical necessity of the service in dispute. The Plan denied your request. The Plan says that there is insufficient clinical information to approve the requested study.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the CT scan. Our reviewer says that the requested items/services is considered medically reasonable and necessary in this case. Our physician reviewer found this enrollee has a history of lung cancer and the requested CT is meant to compare with prior CT scans of the chest and prior PET/CT. The chest x-ray required for documentation of medical necessity is not a valid point. Even if a chest x-ray was normal a CT of the chest would still be necessary to assess the findings seen on prior CT scans. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the CT scan have not been met. Therefore, we decided that the Plan has to pre-approve computed tomography (CT) thorax (71250).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical and occupational therapy to be provided by an out-of-network provider.

You asked the Plan to pre-approve out-of-network physical and occupational therapy. You say that this is the therapy provider for the facility. You say that you have applied for in-network status and are requesting authorization. The Plan denied your request. The Plan says in-network providers are available.

The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services, plans are not required to make payments for any services received by enrollees that are not provided directly by the Plan or through arrangements made by the Plan.

The services at issue in this appeal will not be provided in an emergency or urgent care situation. The Plan is not providing these services and is not making arrangements to provide these services. Therefore, we decided that the Plan does not have to pre-approve physical and occupational therapy to be provided by an out-of-network provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care, for the enrollee.
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found based on the medical records provided there is no documentation that the enrollee requires skilled nursing services, i.e., the specialized skill, knowledge and judgment of a skilled professional nurse are not required to safely and effectively provide medically necessary and reasonable treatment. This enrollee does require skilled therapy services, i.e., the specialized skill, knowledge and judgment of a qualified therapist are required to safely and effectively provide medically necessary and reasonable treatment. Daily skilled services are not required. This enrollee does not require the services on an inpatient basis, only in a skilled nursing facility setting. Services in the home with home health care or in a long-term care facility on a part time basis appear appropriate 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 not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care, for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device.
You asked the Plan to pre-approve the device. You say that this is medically necesasry. The Plan denied your request. The Plan says medical studies have not proven that this device is helpful for treatment of the health problem.
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 device. 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 guideline and peer reviewed literature do not fully support the spinal decompression device procedure over the 'gold standard' of lumbar laminectomy. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of this device for this enrollee's medical condition. FDA indications include implantation of the Superion device at one or two adjacent lumbar levels in patients with moderate spinal stenosis in whom operative treatment is indicated at no more than two levels, from L1 to L5. This enrollee has multiple degrees of spinal stenosis, many not at FDA indicated levels of "moderate" spinal stenosis( including the planned level of implantation L2-3 and L3-4). 
FDA contraindications include spinal instability, scoliosis, obesity, and osteoporosis (which have not been adequately addressed in the medical records). There is no documentation of the enrollee's height, weight or body mass index. There is imaging evidence of scoliosis of the lumbar spine, including no documentation of the Cobb angle. Retrolisthesis (6-7 mm) of L2 on L3 is seen, without discussion of potential instability. There is no discussion indicating that a DEXA scan has demonstrated the lack of significant osteoporosis. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines. Therefore, the request for Vertiflex Superion Interspinous device at levels L2-3 and L3-4 is not medically reasonable or necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CT maxillofacial area; without contrast material (CPT code 70486), for the enrollee.

You asked the Plan to pre-approve the CT scan. You say that the CT scan is necessary. The Plan denied your request. The Plan says there was no documentation of failure of adequate medical treatment for sinusitis submitted with this appeal.

The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the CT scan. Our physician reviewer found the provided notes did not describe the enrollee having failed at least four (4) weeks of conservative testing and treatment for acute sinusitis such as allergy testing, nasal lavage, over-the-counter (OTC) medications, dietary changes or describe a clinically complicated sinusitis to justify imaging earlier than the 4 week treatment trial. Therefore, without sufficient support made for this request, the CT sinus will be considered not medically necessary 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 the CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve CT maxillofacial area; without contrast material (CPT code 70486), for the enrollee.
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 stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
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 complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for alcohol detoxification. Medical conditions are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The enrollee does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program.
Medically necessary services can be provided in a different level of care. There is not a 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-approve acute IRF admission and services.