Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve therapeutic activities, occupational therapy to be provided by the out-of-network provider.

You asked the Plan to pre-approve the therapeutic activities, occupational therapy. The Plan denied your request. The Plan says the Plan did not see that you have a need that must be met by a provider that does not work with the Plan.

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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve therapeutic activities, occupational therapy to be provided by the out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gelsyn-3.

You asked the Plan to pre-approve Gelsyn-3. You say that you would like reconsideration because this drug is medically necessary. The Plan denied your request. The Plan says the member does not meet step therapy exception 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 Gelsyn-3. Our reviewer says that the Plan requires a trial of drug Orthovisc and Monovisc before they will approve the requested drug. In this case, the member has not tried and failed the required drugs. Our physician reviewer found there is no documentation provided indicating that the plan's required drugs 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 Gelsyn-3 have not been met. Therefore, we decided that the Plan does not have to pre-approve Gelsyn-3.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Uloric tab 40mg 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 medication falls under 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 Uloric tab 40mg for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110).

You asked the Plan to pre-approve the complete maxillary denture. You say that you never received the previous dentures. The Plan denied your request. The Plan says this service exceeds the maximum count allowed per period.

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, complete maxillary denture (D5110) is limited to one procedure every five plan years. The record shows that you received a complete maxillary denture (D5110) on August 18, 2017 and your complete maxillary denture (D5110) benefit has been exhausted. Therefore, we decided that the Plan does not have to pre-approve a complete maxillary denture (D5110).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression garments.

You asked the Plan to pre-approve compression garments. You say that you say stocking sleeves, compression hose and compression boots should be covered. The Plan denied your request. The Plan says Medicare does not cover compression stockings or wraps in the absence of open wounds or ulcers.

The Plan must follow Medicare rules. Medicare rules say that compression garments described are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that compression bandages and gradient compression wraps are covered only when they are used as dressings over a qualifying wound.

The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you do not have a medical condition for which compression stockings can be covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve compression garments.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6530.

You asked the Plan to pre-approve the compression stockings. You say that you need compression stockings because of a medical condition. The Plan denied your request. The Plan says compression stockings are not covered.

The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are non-covered because they do not meet the statutory definition of a surgical dressing.

Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6530.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dialysis to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve dialysis. You say that you would like approval for these services. The Plan denied your request. The Plan says there are in-network providers available.

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 after your approved 25 visits. 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 dialysis to be provided by an out of network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuation of home health aide services.

You asked the Plan to pre-approve these services. You say that home health aide services are medically
necessary for the enrollee. The Plan denied your request. The Plan says home health aide services are not
medically necessary.

The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically
necessary for the enrollee to receive skilled nursing or therapy.

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
home health aide services are not medically necessary. Our physician reviewer found that in order to require
home health care skilled services, the member must be confined to the home, under the care of a physician, and
receiving services under a plan of care established and periodically reviewed by a physician. Additionally, the
member must be in need of skilled nursing care on an intermittent basis or physical therapy or speech-language
pathology; or have a continuing need for occupational therapy. Being homebound means leaving home is a
major effort. In this case, the documentation doesn't support that the member requires skilled nursing or skilled
rehabilitation services to provide treatment that is medically necessary. The member does not require skilled
nursing or rehabilitation services to effectively provide treatment, care, and/or services in order to improve the
member's condition, or perform a maintenance program to maintain the member's condition and/or prevent
deterioration. The member has been medically stable without any recent exacerbations of chronic medical
problems or hospitalizations. The requested services are custodial and do not require a skilled professional.
The requested home health aide services are not 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 these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve a continuation of home health aide services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.

You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the member is receiving appropriate in-patient acute care and does not require transfer to LTACH.

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. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH services. 

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 for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa.

You asked the Plan to pre-approve Euflexxa. The Plan denied your request. The Plan says the 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 Euflexxa. Our reviewer says that Euflexxa is not medically reasonable and necessary in this case. Our physician reviewer found that the Plan requires a trial of drug Orthovisc and Monovisc before they will approve the requested drug. In this case, the enrollee has not tried and failed the required drug(s). There is no documentation provided indicating that the Plan's required drug(s) 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 Euflexxa have not been met. Therefore, we decided that the Plan does not have to pre-approve Euflexxa.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the MyoPro powered upper limb orthosis (L8702).

You asked the Plan to pre-approve the orthosis. You say that you are asking for a GAP exception with this prior authorization. The MyoPro device can only be supplied by a small group of highly skilled clinicians that have been trained and certified to fit and program this custom-made device. The Plan denied your request. The Plan says this item is considered experimental and investigational. There is insufficient evidence of its effectiveness in those with stroke and hemiparesis.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The rules also say that experimental and investigational devices are not covered.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the orthosis have not been met. Therefore, we decided that the Plan does not have to pre-approve the Myopro powered upper limb orthosis (L8702).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment with Keytruda (J9271).
You asked the Plan to pre-approve Keytruda. You say that the requested treatment is a medical necessity for the enrollee. The Plan denied your request. The Plan says the requested drug is not medically necessary for the enrollee's condition.
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 Keytruda. Our reviewer says that the requested drug is not medically necessary. Our physician reviewer found that the requested use of Keytruda is not FDA-approved for the enrollee's diagnosis. The use is not supported by one of the major drug compendia or by clinical research that appears in a Medicare-approved medical journal. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have to pre-approve treatment with Keytruda (J9271).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral for out-of-network occupational therapy.

You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says the services can be provided in the network.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and 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 a referral for out-of-network occupational therapy.
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 services can be safely received in other settings, for example: skilled nursing facility.

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 there are no identifiable skilled nursing service needs. 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an auricular peripheral nerve stimulation device for the enrollee.
You asked the Plan to pre-approve these services. You say that this is medically necessary. The Plan denied your request. The Plan says that this service is not a covered Medicare benefit.
The Plan must follow Medicare rules. Medicare rules say that acupuncture for stimulation of auricular points is not a covered Medicare benefit. Therefore, we decided that the Plan does not have to pre-approve an auricular peripheral nerve stimulation device for the enrollee.
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 care can continue to be received in the IRF.

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 there are no identifiable skilled nursing service needs. 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: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve the Dexcom G6.

You asked the Plan to pre-approve the monitor. You say that this is medically necessary for your diabetes. The Plan denied your request. The Plan says that coverage cannot be authorized at this time.

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. The plan has not provided any records to substantiate their denial in this case. There are no records to help determine the enrollee's full diagnosis. There are no notes to help determine if the enrollee's is being insulin-treated with three or more daily injections. There is no documentation showing if the enrollee is testing four times a day, and if the testing results are guiding dose adjustments. Therefore, we decided that the Plan has to pre-approve the Dexcom G6.

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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable controller (E2377, E2313, E2311), wheelchair leg rest (E0990), and gel arm pads (K0108).

You asked the Plan to pre-approve the wheelchair accessories. You say that the items are medically necessary. The Plan denied your request. The Plan says coverage criteria for these accessories has not been met.

The Plan follows Medicare rules. Medicare rules say that wheelchair features and accessories are only covered when 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 wheelchair accessories. Our reviewer says that the requested accessories are not medically necessary. Our physician reviewer found the enrollee's strength and function in the upper extremities indicates that the patient can control any power options through their own individual switches. The leg rests are already included in the power leg lifts and the requested separate leg rests exceed the patient's medical need. Gel arm pads are not primarily medical in nature and are non-covered. 

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 wheelchair accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve an expandable controller (E2377, E2313, E2311), wheelchair leg rest (E0990), and gel arm pads (K0108).