Persius/hicric huggingface dataset:
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 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 care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee did not require any skilled nursing or rehab services on a daily basis at an inpatient level of care. The enrollee did not require skilled therapy to establish a safe and effective maintenance program. As a practical matter, the enrollee did not require any skilled services on an inpatient basis, at a SNF level of care at the time of discharge from the hospital. 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 3D tumor imaging.
You asked the Plan to pre-approve the requested services. You say that the enrollee has left-sided unilateral
rigidity, suggestive of Parkinson's disease. The Plan denied your request. The Plan says medical necessity was
not established.
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 requested services. Our physician
reviewer found that the enrollee is noted to have gait dysfunction with slight rigidity on exam. The requested
test was ordered to evaluate for possible Parkinson's disease. The utility of the requested scans in clinical
practice is largely limited to differentiation between essential tremor and Parkinson's Disease. In this case, the
enrollee is not noted to have any form of tremor. The performance of the scan for the evaluation of suspected
Parkinsonism is not otherwise reflective of the generally accepted standards of practice or care. There is not
sufficient literature available to conclude that the proposed testing is of clinical benefit/diagnostic utility in
such a setting. In as much, the requested service cannot be determined to be reasonable and 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 requested services have not been met. Therefore, we decided that the Plan
does not have to pre-approve 3D tumor imaging.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a total electric hospital bed.
You asked the Plan to pre-approve the bed. You say that you are not able to get up the stairs to your bedroom. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered. While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital bed.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve a ferumoxytol 1 mg injection.
You asked the Plan to pre-approve the ferumoxytol. You say that the ferumoxytol injection is medically
necessary. The Plan denied your request. The Plan says that the injection is not medically necessary as there is
no evidence of failed oral iron supplementation.
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 ferumoxytol. Our reviewer says that
this medication is medically necessary. Our physician reviewer found IV iron is indicated due to symptomatic
nature of the anemia and the profound nature of the iron deficiency. It is unlikely that oral iron alone will be
effective 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 the ferumoxytol have been met. Therefore, we decided that the Plan has to preapprove
a ferumoxytol 1 mg injection.
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 two crowns (D2740) to be rendered by an OON
provider.
You asked the Plan to pre-approve the crowns. You say that you are unable to find a network provider in your
area. The Plan denied your request. The Plan says it is not medically necessary for the crowns to be provided
by an OON provider. The Plan also says that there are available in-network providers in your area.
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
covered when they are received OON. Therefore, we decided that the Plan does not have to pre-approve two
crowns (D2740) to be rendered by an OON provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa (J7323).

You asked the Plan to pre-approve Euflexxa. You say that the enrollee has tried Mobic, APAP, and physical therapy without success. The Plan denied your request. The Plan says the requested drug is subject to step therapy. The Plan says that the provided documentation does not show that the enrollee has trialed and failed the required drugs. The Plan also says that the requested drug is not medically necessary.

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 requested drug is not medically necessary. Our physician reviewer found the provided documentation does not shows that the enrollee has trialed and failed the required drugs, Orthovisc or Monovisc.

Therefore, the reviewer found that the requested drug 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 Euflexxa have not been met. Therefore, we decided that the Plan does not have to pre-approve Euflexxa (J7323).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc One.
You asked the Plan to pre-approve Synvisc One. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the requested drug does not meet step therapy criteria.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain
Part B medications.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve Synvisc One. Our reviewer says that the
documentation does not support that the requested drug is medically reasonable or necessary. Our physician
reviewer found the enrollee has osteoarthritis in the bilateral knees. The enrollee has not trialed
viscosupplemental treatment, Monovisc. Step therapy, as outlined by the plan, requires these be trialed first.
The documentation does not outline contraindications or reasons these medications were not considered.
Without the support of the documentation, Synvisc One is not approved as step criteria is not 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 Synvisc One have not been met. Therefore, we decided that the Plan does not
have to pre-approve Synvisc One.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve durable medical equipment to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve OON services. You say that you need the item, and do not want to pay the full cost. The Plan denied your request. The Plan says the requested device is available within in-network providers.
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 at issue in this appeal. We found no exception that would require the Plan to pre-approve these OON items. Therefore, we decided that the Plan does not have to pre-approve durable medical equipment 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 total electric hospital bed and an over-bed table.

You asked the Plan to pre-approve the items. You say that this is medically necessary, as you are half paralyzed and have dementia. The Plan denied your request. The Plan says these items are not a covered benefit.

The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered. Medicare rules say that items must have a medical purpose in order to be covered. 

While a total electric hospital bed and an over-bed table may be appropriate in this case, neither the Plan nor Medicare offers coverage for these items. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital bed and an over-bed table.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gel-One (J7326).
You asked the Plan to pre-approve Gel-One. You say that Gel-One is medically necessary. The Plan denied
your request. The Plan says a trial of Synvisc/Synvisc-One, Durolane, and Gelsyn-3 is required before Gel-One
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 Gel-One. Our reviewer says that the
Gel-One is not medically necessary. Our physician reviewer found the record shows no record of a trial of the
plan preferred drugs, or any reason why the plan preferred drugs would be unsafe or ineffective 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 Gel-One have not been met. Therefore, we decided that the Plan does not have
to pre-approve Gel-One (J7326).
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 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 LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found there are no services at the LTACH that the enrollee requires that are not already
available and covered at the current facility. Therefore, this request for LTACH services will be considered not
medically necessary at this time. Transfer to a lower level of care may be considered soon.
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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forthe skilled nursing facility (SNF) care provided from July 4, 2020 to August 2, 2020.You asked the Plan to pay forthe SNF care. You say that the SNF care provided from July 4, 2020 to August 2, 2020 was medically necessary.The Plan denied your request. The Plan says the enrollee did not meet criteria for SNF care provided from July 4, 2020 to August 2, 2020.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 care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found as of 7/3/2020 the member did not require any skilled nursing or rehab services on a daily basis.  He was not expected to make measurable gains within a reasonable and predictable period of time or require skilled therapy to prevent deterioration with mobility or activities of daily living.  The member did not require skilled therapy to establish a safe and effective maintenance program.  As a practical matter, the member did not require any skilled services on an inpatient basis, at a SNF level of care during the period of care under review.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 care have not been met.Therefore, we decided that the Plan does not have to pay forthe skilled nursing facility (SNF) care provided from July 4, 2020 to August 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a temporary crown for tooth #14.

You asked the Plan to pre-approve the temporary crown. The Plan denied your request. The Plan says this
service is not covered under your benefit plan.

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
temporary crown for tooth #14.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Brovana 15 mcg/2 ml solution.

You asked the Plan to pre-approve Brovana. You say that the service requested is medically necessary for the enrollee. The Plan denied your request. The Plan says the service does not meet medical necessity guidelines.

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 Brovana. Our reviewer says that the service requested is not considered medically necessary. Our physician reviewer found the medical records do not indicate that Perforomist, the Plan's preferred drug, would be inferior for this patient. Furthermore, the patient is also not already on it.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Brovana have not been met. Therefore, we decided that the Plan does not have to pre-approve Brovana 15 mcg/2 ml solution.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve fold down push handles for a wheelchair.
You asked the Plan to pre-approve the handles. You say that this is medically necessary. The Plan denied your
request. The Plan says this particular item does not improve this wheelchair's function.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose.
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we
decided that the Plan does not have to pre-approve fold down push handles for a wheelchair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a battery backup.

You asked the Plan to pre-approve the backup. You say that the electrical power system is interrupted a lot. The Plan denied your request. The Plan says this is not a covered benefit.

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. 

A backup battery cannot be covered as it is considered duplicative. Therefore, we decided that the Plan does not have to pre-approve a battery backup.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a core buildup, including any pins when required
(D2950).
You asked the Plan to pre-approve the core buildup. You say that the enrollee needs approval for the core
buildup. The Plan denied your request. The Plan says core buildup is not a covered service.

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
core buildup, including any pins when required (D2950).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Lidocaine-Prilocaine Cream.

You asked the Plan to pre-approve Lidocaine-Prilocaine Cream. You say that this drug will be sold to the
enrollee at a pharmacy and brought to the office for administration. The Plan denied your request. The Plan
says this drug is not covered under the enrollee's Medicare Part B benefit.

The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B,
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill.
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be
brought to the office for administration. Since the medication does not represent an expense to the physician
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that
the Plan does not have to pre-approve Lidocaine-Prilocaine Cream.

Benefits for Lidocaine-Prilocaine Cream 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out of
network (OON) provider.
You asked the Plan to pre-approve office services. You say that parking is free at this facility, and there is
someone who can help you get into the office. The Plan denied your request. The Plan says the denial of
authorization for this service is correct, because this provider is out-of-network with the Plan and you can be
treated by 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 medical services to be provided by an out of network (OON) provider.
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 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 care. Our reviewer says that daily
skilled services are not necessary. Our physician reviewer found you did not require skilled therapy to establish
a safe and effective maintenance program. As a practical matter, you did not require any skilled services on an
inpatient basis, at a SNF level of care during the period of care under review.
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.