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

We decided that the Plan does not have to pre-approve Prolia (J0897).

You asked the Plan to pre-approve Prolia. You say that Prolia is medically necessary. The Plan denied your request. The Plan says a trial of oral bisphosphonates or Zoledronic Acid is required before Prolia can be considered.

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 record does not show a trial of the plan preferred drugs or any reason they would be unsafe or ineffective. 

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 (J0897).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acupuncture.
You asked the Plan to pre-approve these services. You say that the services provide relief for your condition.
The Plan denied your request. The Plan says you have used all 10 visits.
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare.
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20
sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the
Plan's rules apply in this case.
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of
the acupuncture services have not been met. Specifically, the file shows that you have used all 10 acupuncture
visits for conditions other than chronic low back pain. Further visits are not covered by Medicare or your
supplemental benefit. Therefore, we decided that the Plan does not have to pre-approve acupuncture.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a walker (E0143).
You asked the Plan to pre-approve a walker. You say that you are afraid that your walker will give out. The Plan denied your request. The Plan says your walker can be repaired if necessary.
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. Equipment which the enrollee owns or is a capped rental item may be replaced in cases of loss or irreparable damage, or due to irreparable wear following the reasonable useful lifetime of the equipment, which cannot be less than 5 years. The file shows that you have a walker that was provided in 2019, less than 5 years ago. The submitted medical records do not show that it has been lost or irreparably damaged. Therefore, we decided that the Plan does not have to pre-approve a walker (E0143).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xgeva (denosumab).
You asked the Plan to pre-approve Xgeva. You say that the enrollee did not tolerate Zometa. The Plan denied your request. The Plan says the requested use is not medically necessary for the enrollee's diagnosis.
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 Xgeva. Our physician reviewer found that the requested use of Xgeva is not FDA-approved for the enrollee's diagnosis. The requested use is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. He is still being worked up for a cause. Mild hypercalcemia does not require immediate treatment. He has an elevated EGFR and is on vitamin D which should be addressed. The documentation does not support that the requested drug is safe and effective and otherwise reasonable and necessary for this 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 Xgeva have not been met. Therefore, we decided that the Plan does not have to pre-approve Xgeva (denosumab).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the crown (D2740) and core buildup (D2950) for tooth #3.
You asked the Plan to pre-approve the crown (D2740) and core buildup (D2950). You say that your mouth is hurting, and you need the work redone as soon as possible. The Plan denied your request. The Plan says the services are only available once every 5 plan years.
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, you also have a maximum benefit of one crown and core buildup per tooth every five years. The Plan paid for a crown and core buildup for tooth #3 provided on May 2, 2018, which exhausted your benefit. Therefore, we decided that the Plan does not have to pre-approve the crown (D2740) and core buildup (D2950) for tooth #3.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve eligibility for the Special Supplemental Benefit for the
Chronically Ill (SSBCI).
You asked the Plan to pre-approve the SSBCI benefit. You say that you should have been approved for this
benefit. The Plan denied your request. The Plan says you do not meet the criteria established to receive the
Special Supplemental Benefit for the Chronically Ill for 2021.
Medicare generally does not cover supplemental benefits. However, the Plan offers a special supplemental
benefit for the chronically ill (SSBCI) 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 Medicare rules for
coverage of the SSBCI benefit have not been met. Specifically, the record does not show that you have been
diagnosed with any of the qualifying diagnoses. Therefore, we decided that the Plan does not have to preapprove
eligibility for the Special Supplemental Benefit for the Chronically Ill (SSBCI)
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies, garments, pads, gloves and skin moisturizers.
You asked the Plan to pre-approve incontinence supplies. You say that the medical records provided will show proof of medical necessity. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies, garments, pads, gloves and skin moisturizers.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the skilled nursing facility (SNF) services rendered from January 20, 2021 to January 29, 2021.
You asked the Plan to waive the copayment for these services. You say that you disagree with the charges. The Plan denied your request. The Plan says the copayment was applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a $0 copayment for days 1-20 and, $184 copayment per day for days 21-39, and $0 copayment for days 40-100 for SNF care.
Review of the file shows that the enrollee received eight days of SNF care from January 20, 2021 to January 29, 2021. The enrollee has been asked to pay a $184 copayment per day for these services, for a total of $1,472. These services fall within the SNF care benefit category. The file shows that these services made up days 30-39 of the 100 day SNF benefit period, as the enrollee received previous services from September 4, 2020 to October 5, 2020 with inpatient hospital admissions from October 6, 2020 to January 20, 2021. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the skilled nursing facility (SNF) services rendered from January 20, 2021 to January 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve excision of hyperplastic tissue - per arch (D7970).

You asked the Plan to pre-approve excision of hyperplastic tissue. You say that this service is medically necessary. The Plan denied your request. The Plan says this service is 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 pre-approve excision of hyperplastic tissue - per arch (D7970).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve antibiotic cream with aloe vera and vitamins.
You asked the Plan to pre-approve these services. You say that this is the only thing that helps you. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and these services is an OTC item. Therefore, we decided that the Plan does not have to pre-approve antibiotic cream with aloe vera and vitamins
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
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 enrollee does not meet the criteria for coverage.
The Plan must follow Medicare rules. Medicare rules say that a therapeutic CGM is covered when specific criteria are met.
We looked at the file and Medicare rules. The records show that the enrollee does not check his blood glucose levels. 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 continuous glucose monitor (CGM).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve gingival irrigation - per quadrant (D4921), oral hygiene instructions (D1330), and topical application of fluoride varnish (D1206).
You asked the Plan to pre-approve gingival irrigation, oral hygiene instruction and fluoride varnish. You say that these services are medically necessary. 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 pre-approve gingival irrigation - per quadrant (D4921), oral hygiene instructions (D1330), and topical application of fluoride varnish (D1206).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve specialist services to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve specialist services. You say that you would like to see an out-of-network provider because you feel like the in-network doctor's do not have good reviews. The Plan denied your request. The Plan says there are in-network providers available for these services.

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 specialist services to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a mastectomy bra (L8000).
You asked the Plan to pre-approve the bra. You say that this is necessary based on a history of malignant neoplasm of breast. The Plan denied your request. The Plan says you have not had a mastectomy.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. This request cannot be considered medically necessary as there is no history of a mastectomy. Based on this information, we decided that Medicare rules for coverage of the bra have not been met. Therefore, we decided that the Plan does not have to pre-approve a mastectomy bra (L8000).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core build up (D2950) and gum surgery for a restorative procedure (D4212).

You asked the Plan to pre-approve the dental services. You say that the requested services are medically necessary. The Plan denied your request. The Plan says core build up is not listed as a covered service. The Plan says that gum surgery for a restorative procedure is not listed as a covered service either.

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 core build up (D2950) and gum surgery for a restorative procedure (D4212).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Fasenra Injection on a 6-week schedule.
You asked the Plan to pre-approve Fasenra Injection, benralizumab, 1 mg (J0517), 30mg given every 6 weeks. You say that the enrollee's breathing is much better with a 6 eek schedule. The Plan denied your request. The Plan says Fasenra 30mg given every 6 weeks is more than the maximum allowed does for the enrollee's indication.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 Fasenra Injection, benralizumab, 1 mg (J0517), 30mg given every 6 weeks. Our reviewer says that based on the medical records provided and the Medicare-approved major drug compendia there is no documentation that supports a 6-week dosage schedule of Fasenra as opposed to the every 8 week maintenance schedule. Our physician reviewer found based on the medical records provided and the Medicare-approved major drug compendia there is no documentation that Fasenra is safe and effective for the patient at a 6 week schedule. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Fasenra Injection, benralizumab, 1 mg (J0517), 30mg given every 6 weeks have not been met. Therefore, we decided that the Plan does not have to pre-approve Fasenra Injection on a 6-week schedule
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that the services are necessary. The Plan denied your
request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that 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
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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Outpatient Mental Health
Decision: Partially Favorable

We decided that the Plan has to reimburse you $3,740 for medication assisted treatment and a take home supply of medicine. We decided that the Plan does not have to reimburse you $198 of the $3,938 requested.
You asked the Plan to reimburse you $3,938 for medication assisted treatment and a take home supply of medicine. You say that the Plan charged you a $50 copayment per day, which is incorrect. The Plan says that each visit had a separate date of service and applied a $50 copayment per day.
The Plan follows Medicare rules. The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as copayments, deductibles and coinsurance). The contracts says that you must pay a $50 copayment for Opioid Treatment Program services from an out-of-network provider. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for your request have been partially met. Specifically, the record indicates that the Plan did not process payment for code G2067. The record also indicates that the Plan applied your $50 copayment responsibility towards more dates of service than you should have been charged for. We find that there were only 17 dates of service that you owe a copayment for (1-14-20, 1-28-20, 2-11-20, 2-25-20, 3-10-20, 3-24-20, 4-21-20, 5-19-20, 6-2-20, 6-16-20, 6-30-20, 7-14-20, 7-28-20, 8-11-20, 8-25-20, 9-8-20, 9-22-20). 17 dates of service x $50 = $850. This means that your copayment responsibility is $850 for the dates of service at issue. The Plan has stated within the record that your responsibility is $4,590. $4,590 - $850 (copayment for 17 dates of service per the EOC) = $3,740. This means that the Plan must reimburse you $3,740 for the 17 dates of service at issue. Therefore, we decided that the Plan must reimburse you $3,740 for the services at issue. We also decided that the Plan does not have to reimburse you $198 of the $3,938 in reimbursement that you have requested.
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 a continuous glucose monitor sensor kit (K0553, K0554).
You asked the Plan to pre-approve the continuous glucose monitor sensor kit. You say that the continuous glucose monitor sensor kit is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent
self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of the continuous glucose monitor sensor kit have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor sensor kit (K0553, K0554).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Coflex device for the enrollee.

You asked the Plan to pre-approve the device. You say that this is medically necessary. 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 the requested device 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 the device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Coflex device for the enrollee.