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

We decided that the Plan does not have to pre-approve Monovisc injections (J7327).
You asked the Plan to pre-approve Monovisc injections. You say that the injections are medically necessary. You say that the enrollee has tried and failed Tramadol, Meloxicam, and Tylenol for over 3 months with no significant relief. You say that the enrollee has had multiple cortisone injections with no significant relief. You also say that the enrollee has completed physical therapy. The Plan denied your request. The Plan says the provider in this case confirmed that this medication would not be provided from the physician's stock. The Plan also says that medications that are supplied by a pharmacy are not covered by Part B Medicare.
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill.
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be brought to the office for administration. Since the medication does not represent an expense to the physician and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that the Plan does not have to pre-approve Monovisc injections (J7327).
Benefits for Monovisc injections 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the cataract surgery (66984) to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the cataract surgery. You say that this request is medically necessary. The Plan denied your request. The Plan says they have in-network providers available to provide the services you need.
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 requested provider in this case is not a network provider with the Plan. 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 these items/services. Therefore, we decided that the Plan does not have to pre-approve the cataract surgery (66984) to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from January 1, 2021, to January 3, 2021.
You asked the Plan to pay for acute inpatient hospital care. You say that incorrect insurance information was provided. You say that you did not determine the correct information until after the enrollee was discharged. You also say that the services should be covered. The Plan denied your request. The Plan says that authorization was not obtained.
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 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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the record supports that the enrollee was discharged once their condition stabilized and improved and he was considered medically stable. The reviewer also found that records showed that at the time of inpatient admission the admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier ED and/or observation care) would span two midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met. Specifically, the file shows that the admitting physician reasonably expected that the enrollee's necessary hospital care would span two midnights Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from January 1, 2021, to January 3, 2021.
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex procedure.
You asked the Plan to pre-approve the Vertiflex procedure. You say that this request is medically necessary. The Plan denied your request. The Plan says this procedure is considered experimental/investigational.
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 Vertiflex procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental. More research is needed to show safety and efficacy of Vertiflex.
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 Vertiflex procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex procedure.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a posterior interspinous decompression spacer procedure.
You asked the Plan to pre-approve insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level (22869). You say that this procedure is the least invasive and cheapest way to hopefully improve your back and leg pain. The Plan denied your request. The Plan says there is lack of evidence to support interspinous spacer devices as safe and effective as the gold standard of surgical decompression.
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 insertion of interlaminar/interspinous
process stabilization/distraction device, without open decompression or fusion, including image guidance when
performed, lumbar; single level (22869). Our reviewer says that the requested items/services are not considered
medically reasonable and necessary in this case. Our physician reviewer found the spacer is experimental.
More research is needed to show safety and efficacy of the device.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of insertion of interlaminar/interspinous process stabilization/distraction device,
without open decompression or fusion, including image guidance when performed, lumbar; single level
(22869) have not been met. Therefore, we decided that the Plan does not have to pre-approve a posterior
interspinous decompression spacer procedure
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ENTYVIO (J3380).
You asked the Plan to pre-approve ENTYVIO. You say that the service is medically necessary. The Plan denied your request. The Plan says the enrollee has not met the step therapy requirements for this drug.
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 ENTYVIO. Our reviewer says that the drug is not medically necessary. Our physician reviewer found a trial of drug stelara is required before the Plan will approve the requested drug. In this case, the patient has not tried and failed the required drug and there is no documentation provided indicating that the Plan's required drug would likely 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 ENTYVIO have not been met. Therefore, we decided that the Plan does not have to pre-approve ENTYVIO (J3380
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary. The Plan denied your request. The Plan says the rules for IRF care have 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 patient was admitted for surgical repair of a hip fracture after a fall. Medical problems are stable. There are no complex nursing or rehabilitation needs.
The patient does not require treatment by multiple therapies, including either physical therapy or occupational
therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for
physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary
rehabilitation program. Finally, there is not a reasonable expectation that this patient 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 inpatient rehabilitation facility (IRF) admission and services.
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 daily physician visits and intensive therapies. The Plan denied your request. The Plan says the enrollee does not need close follow-up with a rehabilitation physician or specialized nursing.
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 the enrollee was admitted to the acute care hospital for non-surgical management of an ankle fracture after a fall. There is functional decline at home since discharge. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the root amputation - per root (D3450), bone graft in conjunction with periradicular surgery- per tooth, single site (D3428) and unspecified preventive procedure, by report (D1999) provided March 9, 2021.
You asked the Plan to pay for the root amputation, bone graft and unspecified preventative procedure. You say that the services were medically necessary and cost-effective. The Plan denied your request. The Plan says these services are not covered under your dental 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 pay for the root amputation - per root (D3450), bone graft in conjunction with periradicular surgery- per tooth, single site (D3428) and unspecified preventive procedure, by report (D1999) provided March 9, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the office visit (99213) rendered by an out-of-network (OON) provider on January 14, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says that the service was rendered by an out of network provider, without prior authorization.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Specifically, an Evidence of Coverage (EOC) booklet indicating the Plan contract was forwarded for review for an incorrect calendar year for the service provided. Therefore, we decided that the Plan has to pay for the office visit (99213) rendered by an out-of-network (OON) provider on January 14, 2021.
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on May 7, 2021.
You asked the Plan to pay for a comprehensive oral evaluation. You say that the service at issue should be paid. The Plan denied your request. The Plan says the service is a covered benefit, but you have exceeded the frequency limit of one every 36 months.
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. We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a comprehensive oral evaluation have not been met. Specifically, the record shows that you had exceeded the frequency limit prior to this service on August 13, 2018. Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on May 7, 2021.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve avelumab (J9023).
You asked the Plan to pre-approve avelumab (J9023). You say that the drug is medically necessary. The Plan denied your request. The Plan says that the drug is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 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 avelumab (J9023). Our reviewer says that the drug is medically necessary. Our physician reviewer found this drug is approved for first-line maintenance treatment of locally advanced or metastatic urothelial carcinoma that has not progressed with first-line platinum-containing chemotherapy. This patient has not received prior systemic therapy. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of avelumab (J9023) have been met. Therefore, we decided that the Plan has to pre-approve avelumab (J9023).
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 testing provided on March 21, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the testing services. You say that the provider signed a statement of medical necessity. The Plan denied your request. The Plan says prior authorization was not obtained.
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 pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
Both the rendering and requesting provider in this case are not a network providers with the Plan. The Plan did not pre-approve the testing services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the Guardant360 testing provided on March 21, 2021 by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia (J0897) 60mg.
You asked the Plan to pre-approve Prolia. You say that based on your most recent bone density test, you have osteoporosis. You say that your doctor recommended beginning Prolia injections every 6 months. You also say that you feel that you need these injections so that you are not at risk for compression fractures. The Plan denied your request. The Plan says the provided documentation does not indicate that the enrollee has a history of an osteoporosis-related fracture or has tried and failed zoledronic acid.
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
request for Prolia is not medically necessary. Our physician reviewer found the Plan requires a trial of drug
zoledronic acid before they will approve the requested drug. The reviewer found that you have not tried and
failed the required drug. The reviewer found that you do not have a history of an osteoporosis-related fracture.
The reviewer found that there is no documentation provided indicating that the Plan's required drug would
likely be less effective and/or likely have adverse effects for you. Therefore, the reviewer found that the
requested drug does not meet the step therapy 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 Prolia have not been met. Specifically, the file does not show that the enrollee
has tried and failed the required drug, zoledronic acid. Therefore, we decided that the Plan does not have to
pre-approve Prolia (J0897) 60mg.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Brovana (arformoterol).
You asked the Plan to pre-approve Brovana (arformoterol). You say that the drug is medically necessary. The
Plan denied your request. The Plan says the enrollee has not met the step therapy requirements for this drug.
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 Brovana (arformoterol). Our reviewer says that the drug is not medically necessary. Our physician reviewer found the Plan requires a trial of drug Perforomist (formoterol) before they will approve the requested drug. In this case, the patient has not tried and
failed the required drug. There is no documentation provided indicating that the Plan's required drug would
likely 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 Brovana (arformoterol) have not been met. Therefore, we decided that the Plan does not have to pre-approve the Brovana (arformoterol).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing (G0483) provided on December 22, 2020.
You asked the Plan to pay for drug testing. You say that this is supported in the records. The Plan denied your request. The Plan says this was billed with the incorrect POS.
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS). We looked at the file and Medicare rules. The testing at issue was billed with POS 81 for an independent laboratory, but the record shows that the sample was not taken in the laboratory. Based on this information, we decided that Medicare rules for coverage of drug testing have not been met. Therefore, we decided that the Plan does not have to pay for drug testing (G0483) provided on December 22, 2020.