Persius/hicric huggingface dataset:
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of Genvisc. You asked the Plan to pre-approve Genvisc. You say that you are appealing with medical records. The Plan denied your request. The Plan says the denial of authorization for Genvisc is correct, because the Plan requires a trial of Orthovisc and Monovisc before it will approve Genvisc. 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 Genvisc. Our reviewer says that the enrollee does not meet the Medicare criteria for a step therapy exception for Genvisc. Our physician reviewer found the documentation submitted does not show that the enrollee has tried and failed Orthovisc and Monovisc. The documentation does not show that Orthovisc and Monovisc would likely be less effective and/or have adverse effects 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 Genvisc have not been met. Therefore, we decided that the Plan does not have to pre-approve use of Genvisc.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Procrit.
You asked the Plan to pre-approve Procrit. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug is not a covered 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 Procrit.
Benefits for Procrit 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.You asked the Plan to pre-approve IRF care. You say that you do not want the enrollee in a skilled nursing facility.The Plan denied your request.The Plan says that the enrollee's needs can be met at a lower level of care.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. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient's medical status does not currently require intensive physician and nursing oversight only in an IRF. The patient may benefit from multiple therapies such as physical and occupational therapy but the documentation does not support that the patient's functional status requires an intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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 for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pontic (D6245) for tooth #4 and retainer crowns
(D6740) for tooth #'s 2, 3, and 5.
You asked the Plan to pre-approve the pontic and retainer crowns. The Plan denied your request. The Plan says
the documents fail to demonstrate a specific medical condition that would preclude the use of a removable
partial denture.
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 pontic and
retainer crowns 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 pontic and retainer crowns. Our
reviewer says that the services do not meet the Plan's coverage criteria. Our physician reviewer found the
medical records provided do not include any information regarding a medical or neurological issue that would
prevent the use of a removable prosthesis. Our reviewer also found that with the likely deterioration of the
upper left side due to decay, and no indication of any inability to wear a removable prosthesis, there is no
medical necessity for the requested fixed bridge from tooth #2 to #5.
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 pontic and retainer crowns have not been met. Therefore, we decided that
the Plan does not have to pre-approve a pontic (D6245) for tooth #4 and retainer crowns (D6740) for tooth #'s
2, 3, and 5.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an extraction (D7210) of tooth #4.
You asked the Plan to pre-approve the extraction. The Plan denied your request. The Plan says the documentation does not support that surgical techniques would be necessary for tooth removal.
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 extraction 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 extraction. Our reviewer says that the service does not meet the Plan's coverage criteria. Our physician reviewer found removal of tooth #4 via bone removal and/or sectioning of the tooth including elevation of a mucoperiosteal flap does not meet the criteria for coverage. 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 extraction have not been met. Therefore, we decided that the Plan does not have to pre-approve an extraction (D7210) of tooth #4.
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 for the enrollee.
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not 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 complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's medical status does not currently require intensive physician and nursing oversight only in an IRF. The documentation does not support that the enrollee's functional status requires an 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 for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Zarxio.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that Zarxio is covered when specific criteria are met. 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 history of neutropenic fever on a high risk chemotherapy regimen in 2018 who is now being treated with reduced dose Gemcitabine/Abraxane for recurrent pancreatic cancer. The office notes do not indicate any recent episode of neutropenic fever. The FDA approved use of Zarxio is to prevent neutropenic fever in such patients who are receiving chemotherapy associated with significant incidence of severe neutropenia with fever. The National Comprehensive Cancer Network (NCCN) guidelines do not recommend the use of prophylactic growth factor us for low risk regimens unless the treatment is with curative intent. Treatment for the enrollee is palliative; therefore, Zarxio 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-approve Zarxio.
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 SNF services. You say that these services are medically necessary.The Plan denied your request. The Plan says that the records do not support the need for daily therapy on an inpatient basis.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 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 skilled nursing facility (SNF) services.
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 for the enrollee.You asked the Plan to pre-approve IRF care. You say that the enrollee meets acute inpatient rehab admission.The Plan denied your request. The Plan says that the needed care can be safely given in a lower level of care.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. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient's medical status does not currently require intensive physician and nursing oversight only in an IRF. The patient may benefit from multiple therapies such as physical and occupational therapy but the documentation does not support that the patient's functional status or endurance level requires an intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee condition does not meet Medicare criteria for IRF 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 for the enrollee.
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 SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that your condition appears to be custodial.
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 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 skilled nursing facility (SNF) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Optune device (E0766). You asked the Plan to pre-approve an Optune device. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee has recurrent GBM.
The Plan follows Medicare rules. Medicare rules say that tumor treatment field therapy (E0766) is covered for the treatment of newly diagnosed Glioblastoma Multiforme (GBM) only when all of the above criteria are met. Tumor treatment field therapy (E0766) will be denied as not reasonable and necessary for the treatment of recurrent GBM. 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 an Optune device. Our reviewer says that the coverage criteria for an Optune device has not been met. Our physician reviewer found the records show that the enrollee has recurrent GBM. The records do not show that the enrollee has histologically confirmed, newly diagnosed, supratentorial GBM. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an Optune device have not been met. Therefore, we decided that the Plan does not have to pre-approve an Optune device (E0766).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient mental health treatment.
You asked the Plan to pre-approve inpatient mental health treatment. You say that the services are necessary.
The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage
criteria has not been met.
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 inpatient mental health treatment. Our
reviewer says that the requested services are not considered medically reasonable and necessary in this case.
Our physician reviewer found based upon review of the records provided, you do not meet the criteria for
continued acute inpatient mental health treatment for the dates in question of July 15, 2020 forward as you
were not shown to be a danger to yourself or others. You were not showing any auditory or visual
hallucinations and you were cooperative/compliant with treatment while not showing any threats to the safety
of yourself or others.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of inpatient mental health treatment have not been met. Therefore, we decided that
the Plan does not have to pre-approve inpatient mental health treatment.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the presumptive and definitive drug testing provided on January 13, 2020.
You asked the Plan to pay for the drug testing. You say that this should be paid as medically necessary as ordered by the treating physician. The Plan denied your request. The Plan says the incorrect POS code was reported on the claim. In addition, there is no handwritten or electronic signature on the order form.
The Plan must follow Medicare rules. Medicare rules say that the POS code reported for lab testing must reflect the location at which the sample was taken. The documentation does not support that this sample was taken at the independent lab. The patient's address is in Arizona and the rendering lab is in California. It is also noted that the sample was not received by the lab until the day after the sample was taken. Based on this information, the POS code 81 is not appropriate for this claim. Therefore, we decided that the Plan does not have to pay for the presumptive and definitive drug testing 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 for the enrollee. You asked the Plan to pre-approve SNF services. You say that SNF services are medically necessary for the enrollee. The Plan denied your request. The Plan says Medicare criteria for SNF services are 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 pre-approve SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the medical records do not show the enrollee requires skilled nursing or skilled therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. Medicare coverage criteria are 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hyalgan for the enrollee.You asked the Plan to pre-approveHyalgan. The Plan denied your request. The Plan says that they did not receive documentation supporting the medical necessity for a step therapy exception.Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contractindicates 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 Hyalgan. Our reviewer says that Hyalgan is not medically reasonable and necessary for the enrollee in this case. The patient has not tried and failed Monovisc and Orthovisc. There is no indication that Monovisc and Orthovisc would likely be less effective and/or likely have adverse effects for the patient. Our physician reviewer found that the enrollee's condition does not meet step therapy criteria for Hyalgan. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Hyalgan have not been met.Therefore, we decided that the Plan does not have to pre-approveHyalgan for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve surgical placement of the implant body, endosteal
implant for teeth 14, 15 and 31 (D0610).
You asked the Plan to pre-approve the dental implants. You say that tooth extraction and surgical placement of
implant advised to restore chewing function in the arch and to retain integrity of the bone and facial structures
as a partial denture may weaken the natural teeth that support it. The Plan denied your request. The Plan says
implants are covered to replace only one tooth in the same part of your mouth. The dentist has asked to replace
more than one tooth in the same part of your mouth with an implant. The dental x-rays and shows the enrollee's
tooth needs to be replaced. A partial plate can be done to replace your missing tooth.
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
implants 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 implants. Our reviewer says
that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found in this instance, an upper partial denture is a reasonable alternative as tooth #16 is
present in the arch to stabilize an appliance distal to the #14 and #15 teeth that require removal. #31 can be
replaced with a removable appliance as well as #32 is present to stabilize an appliance, and when #18 is
restored on the opposing side or the arch #19 and #20 (after root removal) could be replaced on that same
appliance. Given the ability to reasonably restore the arches with alternative methods and the policy limitations,
there is no finding of medical necessity for the requested implant procedures.
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 implants have not been met. Therefore, we decided that the Plan does
not have to pre-approve surgical placement of the implant body, endosteal implant for teeth 14, 15 and 31
(D0610).