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

We decided that the Plan has to pre-approve Mitomycin, Capecitabine, and Dexamethasone.

You asked the Plan to pre-approve Mitomycin, Capecitabine, and Dexamethasone. You say that these drugs are medically necessary for the enrolle's condition. The Plan denied your request. The Plan says that the requested drugs are not medically reasonable and necessary in this case.

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 Mitomycin, Capecitabine, and Dexamethasone. Our reviewer says that the requested drugs are medically necessary. Our physician reviewer found the enrollee is a 75-year-old with left sided colon cancer that is metastatic to liver. In this case, although the requested drugs are not approved by the federal drug administration (FDA) for the enrollee's condition, their use is supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. This documentation supports that the requested drugs are 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 Mitomycin, Capecitabine, and Dexamethasone have been met. Therefore, we decided that the Plan has to pre-approve Mitomycin, Capecitabine, and Dexamethasone.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (D2751) for tooth #5 and a crown (D2791) for
tooth #4.

You asked the Plan to pre-approve the crowns. You say that you need these services to be approved for
coverage. The Plan denied your request. The Plan says these services are not covered.

Medicare generally does not cover dental services. The Plan follows the same rule.

The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement
of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or
paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve a crown (D2751) for
tooth #5 and a crown (D2791) for tooth #4.
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. You say that this is medically necessary.The Plan denied your request. The Plan says step therapy requirements 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 the requirements for coverage of Euflexxa have not been met. Our physician reviewer found the Plan requires a trial of Orthovisc and Monovisc before they will approve the requested drug. The case file does not contain documentation that Orthovisc and Monovisc have been tried and failed or documentation that these drugs would likely be less effective or have adverse effects for the enrollee in this case.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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ground mileage (A0425) and emergency ambulance
transport (A0427) provided on October 22, 2020.

You asked the Plan to pay for the ground mileage and emergency ambulance transport. You say that the
ambulance transport was medically necessary. The Plan denied your request. The Plan says the enrollee could
have been safely transported by another type of motor vehicle.

Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan
follows the same rules.

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 ground mileage and emergency
transport. Our reviewer says that the emergency transport was not medically reasonable and necessary. Our
physician reviewer found the medical records do not support the medical necessity of ambulance services for
this enrollee. Our reviewer found that the enrollee had complaints of chronic symptoms and was
hemodynamically stable. Our physician reviewer also found that the enrollee had no contraindication for other
means of transport to the hospital, such as a stretcher van or taxi.

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 ground mileage and emergency transport have not been met. Therefore, we
decided that the Plan does not have to pay for the ground mileage (A0425) and emergency ambulance transport
(A0427) provided on October 22, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Dexcom G6 receiver, transmitter, and sensor.

You asked the Plan to pre-approve the receiver, transmitter, and sensor. You say that you would like to appeal these items for coverage. The Plan denied your request. The Plan says the Medicare guidelines have not been met because you only inject insulin twice daily.

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 use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of the receiver, transmitter, and sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve a Dexcom G6 receiver, transmitter, and sensor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre 2 CGM and supplies.

You asked the Plan to pre-approve the Freestyle Libre 2 CGM and supplies. You say that you need these items to be approved for coverage. The Plan denied your request. The Plan says the documentation does not support that you inject insulin three or more times per day.

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 use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of the Freestyle Libre 2 CGM and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre 2 CGM and supplies.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF care. You say that inpatient skilled nursing facility care is medically necessary. The Plan denied your request. The Plan says you do not meet criteria for coverage of inpatient skilled nursing facility care.

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 SNF care. Our reviewer says that inpatient skilled nursing facility care is not medically necessary. Our physician reviewer found that you do not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment in a SNF. The documentation does not reveal evidence of complex wound care, new enteral feedings, or other skilled nursing need. Your functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment in a SNF. You do not require skilled nursing or skilled therapy services (or a combination of these services) on a daily basis in a SNF. As a practical matter, you do not require the necessary services 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a porcelain/ceramic crown (D2740).

You asked the Plan to pre-approve the crown. You say that this crown is medically necessary. The Plan denied your request. The Plan says this type of crown is not covered by the enrollee's dental benefit.

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 a porcelain/ceramic crown (D2740).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for Freestyle Libre 14-day sensor.
You asked the Plan to pay for Freestyle Libre 14-day sensor. You say that please process the appeal for Freestyle Libre CGM. The Plan denied your request. The Plan says the provider has not submitted documentation that the enrollee meets the criteria listed.
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 Freestyle Libre 14-day sensor have not been met. Therefore, we decided that the Plan does not have to pay for Freestyle Libre 14-day sensor.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF 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 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found although further rehab services would be appropriate to improve function, as a practical matter, the intermittent skilled services can be provided at a lower level of care than a skilled nursing facility. 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 care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the insertion of a non-tunneled centrally inserted central venous catheter (36556) provided on November 10, 2020.You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment.The Plan denied your request. The Plan says the record does not support the billed service.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.In this case, the CPT Code Manual definition of code 36556 is the Insertion of non-tunneled centrally inserted central venous catheter; age 5 years or older.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 this service. Our reviewer says that the record does not support the service billed in this case. Our physician reviewer found that the documentation provided did not include the insertion of a central venous catheter, and therefore, this procedure cannot be confirmed as performed. "For Medicare to consider coverage and payment for any item or service documentation submitted by the supplier or provider must corroborate documentation in the patient's medical documentation to confirm Medicare coverage criteria have been met".We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this service have not been met.Therefore, we decided that the Plan does not have to pay for the insertion of a non-tunneled centrally inserted central venous catheter (36556) provided on November 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve subcutaneous sensors (A9276) and a transmitter (A9277) to be used with an interstitial continuous glucose monitor.

You asked the Plan to pre-approve subcutaneous sensors and a transmitter. You say that the requested items are a necessity for you because you can no longer feel when you have low blood sugar levels. The Plan denied your request. The Plan says rules for supplies to be used with a continuous glucose monitor have not been met.

The Plan must follow Medicare rules. Medicare rules say that codes A9276 and A9277 describe the supplies used with a non-therapeutic continuous glucose monitor. 

The requested items are supplies used with a non-therapeutic continuous glucose monitor. Medicare does not cover non-therapeutic continuous glucose monitors or related supplies. Therefore, we decided that the Plan does not have to pre-approve subcutaneous sensors (A9276) and a transmitter (A9277) to be used with an interstitial continuous glucose monitor.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of a Coflex interspinous stabilization
device (22867).

You asked the Plan to pre-approve this service. You say that this service is medically necessary for the
enrollee. The Plan denied your request. The Plan says this service 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 this service. Our reviewer says that the
requested service is not considered medically reasonable and necessary in this case. Our physician reviewer
found that the Coflex device remains experimental in spinal surgery. 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 this service have not been met. Therefore, we decided that the Plan does not have to pre-approve the insertion of a Coflex interspinous stabilization device (22867).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 3 Euflexxa injections.

You asked the Plan to pre-approve the Euflexxa injections. You say that the clinical information provided supports the need for the requested injection services. The Plan denied your request. The Plan says the records provided do not show that the criteria for coverage have 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 the Euflexxa injections. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the medical records provided do not show that the enrollee has tried and failed the drugs that the Plan requires a trial of. Our physician reviewer found that there is no indication that the Plan's required drugs would likely be less effective and/or likely have adverse effects for the enrollee. Our physician reviewer found that the records show the enrollee's use of Euflexxa was in the past and that she is not actively receiving treatment with this drug.

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 Euflexxa injections have not been met. Therefore, we decided that the Plan does not have to pre-approve 3 Euflexxa injections.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a grab bar.
You asked the Plan to pre-approve a grab bar. You say that this is to prevent falling in the shower from unsteadiness and loss of balance. 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 grab bars are not covered because they are not primarily medical in nature. While a grab bar may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a grab bar.
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 you have been having in home physical therapy, but your physician feels it would be beneficial for you to participate in an inpatient physical therapy, occupational therapy, and speech therapy program. You say that you can tolerate this level of therapy. The Plan denied your request. The Plan says the enrollee could receive the care needed in another setting.

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 was admitted for lumbar osteomyelitis and was discharged home with home health services on April 5, 2021. The enrollee's medical conditions are stable. There are no complex nursing or rehabilitation needs. 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the enrollee needs an IRF admission.The Plan denied your request. The Plan says the enrollee would not be able to tolerate 3 hours of intensive therapy per day.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 there are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The patient 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 patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.