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

We decided that the Plan does not have to pre-approve Natesto Gel.

You asked the Plan to pre-approve Natesto. You say that the enrollee has had great success in the past with Natesto Gel. The Plan denied your request. The Plan says Natesto to be taken at home is not covered under the Part B benefit.

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 Natesto Gel.

Benefits for Natesto Gel 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the pneumatic compression device to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve the pneumatic compression device. You say that the requested compression device is medically necessary. The Plan denied your request. The Plan says they have approved coverage for a compression device that performs the same function from an in-network provider.

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 pneumatic compression device 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 group 2 power operated vehicle (POV) (K0806).

You asked the Plan to pre-approve a group 2 POV. You say that this request is medically necessary. The Plan denied your request. The Plan says this is not a covered service.

The Plan must follow Medicare rules. Medicare rules say that a Group 2 POV coded with K0806 will not be covered. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a group 2 power operated vehicle have not been met. Therefore, we decided that the Plan does not have to pre-approve a group 2 power operated vehicle (POV) (K0806).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continued referral to an out-of-network provider for CPAP.

You asked the Plan to pre-approve the continued referral. You say that this is medically necessary. The Plan denied your request. The Plan says two months of transition of care with the out-of-network provider can be covered.

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 provider at issue in this case is not a network provider with the Plan. 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 continued referral. Our reviewer says that the plan's two month extension is reasonable and necessary. Our physician reviewer found it is not medically necessary to continue beyond two months with an out-of-network PAP provider. A two month extension of coverage for the purpose of transition to an in-network provider is sufficient. 

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 continued referral have not been met. 

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 the continued referral. Therefore, we decided that the Plan does not have to pre-approve a continued referral to an out-of-network provider for CPAP.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable ventilator (E0466).

You asked the Plan to pre-approve the portable ventilator. You say that the ventilator is medically necessary.
The Plan denied your request. The Plan says coverage rules have not been met.

The Plan must follow Medicare rules. Medicare rules say that ventilators used to provide Continuous Positive
Air Pressure (CPAP), or bi-level PAP therapy will be denied as not reasonable and necessary.

We looked at the file and Medicare rules. In this case, the ventilator is being used to provide BiPAP level
therapy. This need can be met with an E0471 BiPAP device. Based on this information, we decided that
Medicare rules for coverage of the portable ventilator have not been met. Therefore, we decided that the Plan
does not have to pre-approve a portable ventilator (E0466).
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve CT scan of the chest with contrast for the enrollee.

You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your request. The Plan says that further imaging cannot be approved without knowing the outcome of the prior approved study.

The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the scan. Our reviewer says that the requested scan is medically reasonable and necessary. Our physician reviewer found the enrollee has a history of colon cancer, and now has a renal lesion that is suspicious for malignancy. It is reasonable to obtain a chest CT to rule out pulmonary metastases given this history. A CXR or chest ultrasound would not provide sufficient detail to rule out early metastases. 

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 scan have been met. Therefore, we decided that the Plan has to pre-approve CT scan of the chest with contrast for the enrollee.

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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued physical therapy services.

You asked the Plan to pre-approve physical therapy. You say that this therapy has been helping you keep tendons and knee joints loose so you can walk more and have reduced pain. The Plan denied your request. The Plan says the denial of additional physical therapy is correct, because your condition is chronic and does not require ongoing physical therapy services.

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 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 physical therapy. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the additional requested therapy is not generally accepted as specific and effective therapy for your condition, beyond what was already approved by the Plan. You have had prior therapy and the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or under the supervision of a therapist. You have been instructed in a home exercise program. The requested services are not part of a maintenance 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 physical therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve continued physical therapy services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone marrow aspirate for a surgery for the enrollee.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says medical studies have not proven that this procedure 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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is a lack of large volume, long-term peer-reviewed outcome studies to support the use of bone marrow aspirate for this enrollee's medical condition. There is no specific indication provided to support the request for bone marrow aspirate for the approved surgery. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines. Therefore, the request for bone marrow aspirate for surgery is not medically reasonable or 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 the services have not been met. Therefore, we decided that the Plan does not have to pre-approve bone marrow aspirate for a surgery 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).

You asked the Plan to pre-approve admission to a SNF. You say that the requested admission to a SNF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF admission.

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 admission to a SNF. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found this enrollee does not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse required to safely and effectively provide medically necessary and reasonable treatment in a SNF. The enrollee continues 5/6/21 to have uncontrolled blood pressure and worsening renal function and needs further acute care management. It is unclear whether the enrollee's severe cervical stenosis is causing right arm weakness and balance issues, and this is concerning for possible cord compromise and should be further evaluated prior to participating in further therapy that may involve the neck. At this time skilled nursing or therapy services are not required on a daily basis or as a practical matter on an inpatient basis, in a skilled nursing facility setting. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of admission to a SNF have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH is not medically necessary.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested admission to a LTACH is not medically necessary. Our physician reviewer found based on the documentation provided, the enrollee is currently undergoing treatment at an acute care hospital (ACH) for chronic pneumonia and respiratory failure. The enrollee was transiently intubated/ventilated but is no longer intubated/ventilated. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve crowns (D2752) and core build up (D2950) for teeth # 7, 8, 9, and 18.

You asked the Plan to pre-approve the dental services. You say that these teeth have fillings with recurrent decay that re no longer providing a good sealing. You say that this is causing the enrollee sensitivity. You say that the teeth are no longer restorable with just a composite filling. You also say that core build up and crowns would restore the teeth and prevent them from fracturing. The Plan denied your request. The Plan says the requested crowns and core build up are not medically necessary.

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. The Plan covers the dental services when the services are medically necessary and reasonable. 

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 dental services. Our reviewer says that the requested crowns and core build up are not medically necessary. Our physician reviewer found the provided x-rays reveal existing restorations on all involved teeth, with a deep carious lesion on tooth #18. The reviewer found that in this instance, none of the teeth show sufficient damage as to be in need of full coverage restorations. The reviewer found that where crowns are not indicated, core buildups are not considered. Therefore, the reviewer found that the criteria for crowns and core buildups have not been met. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental services have not been met. Therefore, we decided that the Plan does not have to pre-approve crowns (D2752) and core build up (D2950) for teeth # 7, 8, 9, and 18.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve immunoglobulin replacement therapy.

You asked the Plan to pre-approve immunoglobulin replacement therapy. You say that the requested immunoglobulin replacement therapy is medically necessary. The Plan denied your request. The Plan says that the requested immunoglobulin replacement therapy is not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve immunoglobulin replacement therapy. Our reviewer says that the requested immunoglobulin replacement therapy is medically necessary. Our physician reviewer found the enrollee is with a history of specific antibody deficiency and recurrent sinopulmonary infections. He has been treated with prophylactic doxycycline while awaiting approval of immunoglobulin replacement therapy. While the medical records demonstrate that this enrollee has not had an infection during the short period of time that he has been treated with prophylactic antibiotics, it would also be medically appropriate to treat his specific antibody deficiency with immunoglobulin replacement therapy. The current guidelines do not mandate or recommend one avenue over another in regard to the treatment of specific antibody deficiency and instead the treatment decision should be tailored to the needs and history of the specific individual with the condition and be decided by the treating physician. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of immunoglobulin replacement therapy have been met. Therefore, we decided that the Plan has to pre-approve immunoglobulin replacement therapy.

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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve adult sized disposable diapers.

You asked the Plan to pre-approve incontinence supplies. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the requested supplies are 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 adult sized disposable diapers.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a specialist consultation to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve the out-of-network specialist consultation. You say that you would like reconsideration because you received a second opinion that was not helpful. The Plan denied your request. The Plan says there are several available in-network providers who are able to perform the requested service.

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 specialist consultation to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve intravenous immune globulin (IVIG) for the enrollee.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says this medication is not approved for use to treat this specific condition.

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 services. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found there is no evidence of any approved indication for IVIG. The enrollee has a very rare syndrome - 1.5 cases out of a million people. The request is considered not medically reasonable or 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 the services have not been met. Therefore, we decided that the Plan does not have to pre-approve intravenous immune globulin (IVIG) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a sensor for an interstitial CGM (A9276).

You asked the Plan to pre-approve an interstitial CGM sensor. You say that the requested item is a necessity for you. The Plan denied your request. The Plan says rules for a CGM sensor have not been met.

The Plan must follow Medicare rules. Medicare rules say that only therapeutic CGMs and corresponding supplies can be covered as DME. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an interstitial CGM sensor have not been met. Specifically, the item coded A9276 is not classified as DME and cannot be covered under the DME benefit. Therefore, we decided that the Plan does not have to pre-approve a sensor for an interstitial CGM (A9276).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Oxervate eye drops for the enrollee.

You asked the Plan to pre-approve this drug. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says that this is not covered under Part B.

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 Oxervate eye drops for the enrollee.

Benefits for this drug may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.