Persius/hicric huggingface dataset:
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 a LTACH admission is medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of a LTACH admission.
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 enrollee does not meet Medicare criteria for coverage of LTACH services. Our physician reviewer found that there is no documentation provided necessitating admission to a LTACH. The enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ilumya
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 the services are 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has a diagnosis of psoriasis vulgaris. He has not tried and failed the plan's required drugs of Remicade or Inflectra and Stelara. The records do not show that the required drugs would be less effective or contraindicated for the enrollee; therefore, Ilumya is not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve Ilumya
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of a hypoglossal nerve stimulator (0466T and 64586).
You asked the Plan to pre-approve the insertion of a hypoglossal nerve stimulator. You say that this is medically necessary The Plan denied your request. The Plan says this is not covered
The Plan follows Medicare rules. Medicare rules say that hypoglossal nerve stimulators are covered when the enrollee has had a polysomnography (PSG) performed within 24 months of first consultation for the implant. 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 insertion of a hypoglossal nerve stimulator. Our reviewer says that the criteria for coverage of the requested services have not been met. Our physician reviewer found the enrollee's most recent documented sleep study was in December 2016. His consultation for the implant was in September of 2019, more than 24 months later. Therefore, he does not meet the coverage criteria. 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 insertion of a hypoglossal nerve stimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve the insertion of a hypoglossal nerve stimulator (0466T and 64586).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the benefit allowance of $300 for eyeglasses provided on June 27, 2019.
You asked the Plan to pay the benefit allowance of $300 for the eyeglasses. The Plan denied your request. The Plan says you must choose an in-network provider to receive the benefit allowance of $300. Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. We looked at the file and the Plan's rules. The file shows that the requested provider in this case is not a network vision provider with the Plan. Therefore, we decided that the Plan does not have to pay the benefit allowance of $300 for eyeglasses on June 27, 2019.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approvea Glucose Monitoring System (A9276, A9277, A9278).You asked the Plan to pre-approvethe Glucose Monitoring System. You say that the glucose monitoring system is medically necessary.The Plan denied your request. The Plan says that there is no diagnosis of diabetes.The Plan follows Medicare rules. Medicare rules say that there must be a diagnosis of diabetes for a Glucose Monitoring System to be 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 Glucose Monitoring System. Our reviewer says that the Glucose Monitoring system is medically necessary. Our physician reviewer found the records show that the enrollee has a diagnosis of Type 2 Diabetes and has had episodes of severe hypoglycemia.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 Glucose Monitoring System have been met.Therefore, we decided that the Plan has to pre-approvea Glucose Monitoring System (A9276, A9277, A9278).If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveadmission to a skilled nursing facility (SNF).You asked the Planto pre-approvethe SNF admission. You say that the enrollee requires care in the SNF setting.The Plandenied your request. The Plansaysthe enrollee's needs are mainly custodial as daily skilled nursing or therapy services are not required.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 correctin denying the request to pre-approve the SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee is a female with dementia and history of stroke who was admitted after a fall with a dramatic change in mental status. She has increased lethargy, non ambulatory, poor oral intake. She had hypernatremia, severe on admit and this came down slowly. She has a distal left clavicle fracture, UTI and was put on antibiotics. This patient does not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment. The patient does not have a complex wound care or other SNF level skilled nursing need. This patient's functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist required to safely and effectively provide medically necessary and reasonable treatment in a SNF. The patient does not require these skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis". As a practical matter this patient does not require the necessary services on an inpatient basis, in a skilled nursing facility setting.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the SNF admission have not been met.Therefore, we decided that the Plandoes not haveto pre-approveadmission to a skilled nursing facility (SNF).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve One Touch Ultra Blue test strips.
You asked the Plan to pre-approve the One Touch Ultra Blue strips. You say that this brand of test strips are necessary. The Plan denied your request. The Plan says there is no documentation to support that the requested brand is medically necessary. A 90-day supply has been approved in order for the enrollee to be able to transition to one of the preferred brands.
The Plan must follow Medicare rules. Medicare rules say that Plans are allowed to cover only certain brands of equipment/supplies as long as all medically necessary brands are available. No specific rationale is provided to support that this specific brand is medically necessary. There are no records submitted and nothing to suggest that the preferred brands would be medically inappropriate. Therefore, we decided that the Plan does not have to pre-approve One Touch Ultra Blue test strips.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveBuprenorphine patch.You asked the Plan to pre-approveself-administered drugs. You say that the enrollee has had a very good outcome with this drug.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-approveBuprenorphine patch.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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from September 12, 2019 to October 11, 2019. You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee's condition no longer required daily skilled services at an inpatient skilled nursing facility (SNF) 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 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 pay for the skilled nursing services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 skilled nursing services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided from September 12, 2019 to October 11, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve MRI of the pelvis (72197).
You asked the Plan to pre-approve the MRI. You say that the enrollee's rising PSA levels supports the need for an MRI. The Plan denied your request. The Plan says there is no indication that a repeat MRI of the pelvis is warranted.
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 MRI. Our reviewer says that there is no evidence that the enrollee has had a prostate biopsy or that surgical planning is being undertaken. Our physician reviewer found a recent MRI of the pelvis did not show evidence of prostate malignancy. The requested MRI is not shown to be medically necessary or 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 the MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve MRI of the pelvis (72197).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH service
You asked the Plan to pre-approve the LTACH services. You say that the enrollee has multiple acute complex conditions that require very close physician monitoring. The Plan denied your request. The Plan says the enrollee's care can be adequately provided in a skilled nursing facility.
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 physician reviewer found that the enrollee is currently undergoing treatment at an acute care hospital (ACH) for bacteremia and multiple areas of infection. The enrollee has undergone surgical washouts and drainage. The enrollee is receiving a prolonged course of antibiotics. The enrollee is not intubated/ventilated. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. 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) service
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF admission.You asked the Plan to pre-approve SNF admission. You say that the member has a decreased sustained activity tolerance and is ready for a lower level of care. The Plan denied your request. The Plan says the member does not meet medical criteria.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 admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the member's care can be continued at an alternate level of care.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 admission have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF admission.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of Euflexxa.
You asked the Plan to pre-approve Euflexxa. You say that you are appealing with records. The Plan denied
your request. The Plan says the denial of authorization for Euflexxa is correct, because the Plan requires a trial
of Orthovisc and Monovisc before it will approve Euflexxa.
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 Euflexxa. Our reviewer says that the
enrollee does not meet the Medicare criteria for a step therapy exception for Euflexxa. Our physician reviewer
found the enrollee has not tried and failed the Plan's preferred drugs of Orthovisc and Monovisc. The
documentation does not support that Orthovisc and Monovisc would likely be less effective and/or 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 Euflexxa have not been met. Therefore, we decided that the Plan does not have
to pre-approve use of Euflexxa.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve a TENS unit (E0730 and A4595).
You asked the Plan to pre-approve a TENS unit. You say that the TENS unit is medically necessary for treatment of the member's condition. The Plan denied your request. The Plan says that the member is not enrolled in a clinical study.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 a TENS unit. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found per the LCD, the TENS unit is indicated for treatment of the member's neck 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 TENS unit have been met. Therefore, we decided that the Plan has to pre-approve a TENS unit (E0730 and A4595).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a total electric hospital bed. You asked the Plan to pre-approve the fully electric bed. You say that you definitely need a fully electric hospital bed so you can transfer from your wheelchair to the bed safely. The Plan denied your request. The Plan says Medicare only covers semi-electric hospital beds. The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered. While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital bed.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gel One for the enrollee.
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 the step therapy requirement is not 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 these services. Our reviewer says that
the services are not medically necessary. Our physician reviewer found the enrollee has a diagnosis of
unilateral primary osteoarthritis of the left knee. He has not fried and failed the plan's required drugs of
Orthovisc and Monovisc. The records do not show that the required drugs would be less effective or
contraindicated; therefore, Gel One is not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve Gel One for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Symbicort 80-4.5mcg inhaler for the enrollee.
You asked the Plan to pre-approve the inhaler. You say that this is medically necessary. The Plan denied your
request. The Plan says this is not a covered benefit, as it is a self-administered drug.
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 Symbicort 80-4.5mcg
inhaler for the enrollee.
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 services are not medically necessary. Our physician reviewer found the enrollee is currently undergoing treatment at an acute care hospital (ACH) for a urinary tract infection and seizures due to medication non-compliance. The enrollee is receiving antibiotics and has had her seizure medications resumed. The enrollee is not intubated/ventilated. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. 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