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

We decided that the Plan does not have to pre-approve Cetuximab 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 is not being requested for a use approved by the FDA or supported by one of more citations in the approved compendia.
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 the drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found the documentation includes a report from Foundation One CDx indicating the enrollee's cancer has a KRAS mutation. Cetuximab is approved and supported for use in KRAS wild-type, meaning not mutated, metastatic colon cancer. Therefore the submitted documentation does not support that Cetuximab is medically reasonable and necessary, nor that it is safe and effective 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 the drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Cetuximab for the enrollee.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa.You asked the Plan to pre-approvethese 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. She has not tried and failed the Plan's required drugs of Orthovisc and Monovisc. The records do not show that the required drugs would be contraindicated or less effective; therefore, the Euflexxa is not reasonable or 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-approveEuflexxa.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based composite provided on February 24, 2020. 
 
You asked the Plan to pay for the resin-based composite. You say that your provider called prior to the service being rendered to see how much would be covered by the Plan. The Plan denied your request. The Plan says your annual benefit has been exhausted. 
 
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 Plan offers a $1,000 annual dental benefit maximum. The contract says that after your annual maximum benefit maximum has been met, you are responsible for the full charges of any additional dental services. The record shows that you met the annual maximum benefit with the processing of this claim on February 24, 2020 and your annual maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the resin-based composite provided on February 24, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia (Denosumab code J0897).You asked the Plan to pre-approve Prolia. You say that Prolia is the best treatment option for the enrollee.The Plan denied your request. The Plan says the compendia does not support using this drug to treat osteopenia in male enrollee's without prostate cancer undergoing androgen deprivation treatment who are at high risk for fracture.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 Prolia. Our reviewer says that Prolia does not meet coverage criteria. Our physician reviewer found based on the provided medical records, the requested use of Prolia (Denosumab code J0897) is not Food and Drug Administration (FDA)-approved for the enrollee's diagnosis. Our reviewer found that the use of Prolia is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. Our physician reviewer also found that the use of Prolia is not supported for a male with osteopenia (not receiving androgen deprivation therapy) with no reported history of osteoporotic fracture.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 (Denosumab code J0897).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Nujolix (belatacept) injections to be provided in the home health setting for the enrollee.
You asked the Plan to pre-approve Nujolix injections. You say that this is medically necessary to keep the enrollee from rejecting the kidney transplant. The Plan denied your request. The Plan says patients receiving Nulojix should be managed in facilities equipped and staffed with adequate laboratory and supportive medical resources.
The Plan must follow Medicare rules. Medicare rules say that the immunosuppressive drug belatacept is not proven to be safe when administered in the home and cannot be covered in that setting. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Nujolix injections have not been met. Therefore, we decided that the Plan does not have to pre-approve Nujolix (belatacept) injections to be provided in the home health setting for the enrollee.
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 inpatient rehabilitation services are medically necessary.The Plan denied your request. The Plan says rules for coverage 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 above.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 enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to be able to perform fifteen hours per week of rehabilitative services or to require regular physician evaluation. The enrollee's care needs can be met at a lower 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 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forthe skilled nursing facility (SNF) services provided December 21, 2018 to January 13, 2019.You asked the Plan to pay forthe SNF services. You say that you feel that the plan should cover for continued SNF services.The Plan denied your request. The Plan says the Medicare criteria for continued SNF level of coverage were not met.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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing and skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis and 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 SNF services have not been met.Therefore, we decided that the Plan does not have to pay forthe skilled nursing facility (SNF) services provided December 21, 2018 to January 13, 2019
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.You asked the Plan to pre-approve SNF services.. You say that you require more time in a SNF.The Plan denied your request. The Plan says that continued therapy services can be provided on an intermittent basis at a lower 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 pre-approve SNF services.. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for continued SNF 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 SNF services. have not been met.Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on
January 13, 2020.
You asked the Plan to waive the copayment for the ambulance transport. You say that you weren't aware the
copayment applies to each ambulance transport. You say that there shouldn't be a second ambulance
copayment. The Plan denied your request. The Plan says the copayment 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 $275 copayment per one-way trip by ground or air ambulance.
The enrollee has been asked to pay a $275 copayment for the ambulance transport. The ambulance transport
falls within the "Ambulance services" benefit category. The ambulance copayment applies per one-way trip for
ground transport. 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 ambulance transport
provided on January 13, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. You asked the Plan to pre-approve the SNF services. You say that the records provided support the need for SNF care. The Plan denied your request. The Plan says the enrollee appears to be at or near baseline level of function. The Plan says that there is no daily skilled nursing need such as IV medication or complex wound care needs. The Plan says that the enrollee's needs can be met at a lower level of care and appear custodial in nature. 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 the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral and inhaled medications and insulin. The enrollee had stable vital signs, MASD to his coccyx, and clear lungs. The enrollee received physical therapy and occupational therapy in the acute hospital. The enrollee was at contact guard assist level with functional mobility, including gait to 100 feet with a rolling walker. The enrollee required varying assist with activities of daily living. There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. 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 services have not been met.Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the MRI provided on November 21, 2019.
You asked the Plan to waive the copayment for the MRI. You say that you were not told that it would cost anything out-of-pocket. You say that you feel you don't owe anything. The Plan denied your request. The Plan says the copayment 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). Your contract with the Plan clearly says that you must pay a $225 copayment for each in-network, Medicare-covered advanced imaging service. You have been asked to pay $189.28, which is less than the standard $225 copayment for the MRI. The MRI falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the MRI provided on November 21, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Coronary Computed Tomography Angiography
(CCTA) with Calcium scoring (75571).
You asked the Plan to pre-approve the CCTA. You say that the CCTA is medically necessary. The Plan denied
your request. The Plan says rules for coverage have not been met.
The Plan follows Medicare rules. Medicare rules say that CCTA is not covered for screening purposes.
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 CCTA. Our reviewer says that the
requested service is not medically necessary. Our physician reviewer found the patient has increased coronary
risk but no symptoms or findings suggestive of coronary ischemia. In this circumstance treatment based on
screening coronary CT scanning and calcium scoring has not been shown to improve cardiac outcome
incremental to that achievable with standard risk factor profiling and basic lipid analysis.
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 CCTA have not been met. Therefore, we decided that the Plan does not have
to pre-approve Coronary Computed Tomography Angiography (CCTA) with Calcium scoring (75571).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a total shoulder arthroplasty (23472). 
 
You asked the Plan to pre-approve a total shoulder arthroplasty. You say that that physical therapy has not improved the enrollee's condition. The Plan denied your request. The Plan says this is not medically necessary. 
 
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 a total shoulder arthroplasty. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation of a recent trial and failure of physical therapy. Surgery is therefore not needed 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 a total shoulder arthroplasty have not been met. Therefore, we decided that the Plan does not have to pre-approve a total shoulder arthroplasty (23472).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.
You asked the Plan to pre-approve these service. You say that you disagree with the denial. The Plan denied
your request. The Plan says the admission is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed 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 these service. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to the hospital
on June 15, 2020 with a femur fracture and underwent surgical repair. The occupational therapy note states she
is at her baseline level of function for activities of daily living. She has no skilled nursing or skilled therapy
needs. She does not need skilled nursing or skilled therapy on a daily basis. As a practical matter, the enrollee
does not require the necessary services on an inpatient basis at the SNF 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 these service have not been met. Therefore, we decided that the Plan does not
have to pre-approve a skilled nursing facility (SNF) admission.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an oral nutritional product.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your
request. The Plan says enteral nutrition products that are administered orally are a non-covered benefit.
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 an oral nutritional product.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveDupixent 300mg/2ml injection for the enrollee.You asked the Plan to pre-approvethe drug. You say that this is medically necessary.The Plan denied your request. The Plan says this medication is denied due to a benefit exclusion.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-approveDupixent 300mg/2ml injection for the enrollee.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve OPDIVO and IMLYGIC.
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan denied your request. The Plan says that the services are not medically necessary.
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 these services. Our reviewer says that the services are medically necessary. Our physician reviewer found the enrollee has lentigo and malignant melanoma of the neck and scalp. He has both locally advanced melanoma treated with OPDIVO since February of 2020 and new lesions on his forehead. Continuing OPDIVO for systemic therapy of advance disease is the standard of care and medically necessary. IMLYGIC is FDA-approved for the treatment of local unresectable cutaneous, subcutaneous, and nodal lesions in patients with melanoma recurrent after initial surgery. This enrollee has had multiple prior surgeries and no lesions are not felt to be resectable. IMLYGIC is a localized therapy injected into the tumor. IMLYGIC is therefore reasonable and 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 been met. Therefore, we decided that the Plan has to pre-approve OPDIVO and IMLYGIC.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve MILD (0275T).
You asked the Plan to pre-approve MILD. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says there is no clear indication that this procedure is medically necessary and therefore, the standard of care and literature would not support its use.
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 MILD. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this procedure is experimental and more research is needed to show the safety and efficacy of the MILD procedure. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of MILD have not been met. Therefore, we decided that the Plan does not have to pre-approve MILD (0275T).