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

We decided that the Plan does not have to pre-approve Daliresp 500mcg tablets.You asked the Plan to pre-approve the Daliresp tablets. You say that this medication is medically necessary.The Plan denied your request. The Plan says this oral drug is not covered by Medicare 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 Daliresp 500mcg tablets.Benefits for the Daliresp tablets 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for bitewings -four radiographic images (D0274), intraoral -periapical each additional radiographic image (D0230), periodontal maintenance (D4910) and periodic oral evaluation -established patient (D0120) provided on January 14, 2020.You asked the Plan to pay for the dental services. You say that you are appealing for reconsideration of the denied charges.The Plan denied your request. The Plan says you exhausted your 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.Your EOC does not provide a benefit for periodontal maintenance. Your EOC provides a benefit for one periapical x-ray per calendar year.The Plan has already approved payment of one of the three periapical x-rays you had for calendar year 2020. You do not meet the conditions for approval of periodontal maintenance and 2 additional periapical x-rays (D0230 x2 ) for the calendar year 2020.Therefore, we decided that the Plan does not have to pay forbitewings -four radiographic images (D0274), intraoral -periapical each additional radiographic image (D0230), periodontal maintenance (D4910) and periodic oral evaluation -established patient (D0120) provided on January 14, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Invokana.
You asked the Plan to pre-approve Invokana. You say that the enrollee has been on this drug for years. The Plan denied your request. The Plan says The enrollee's Part B coverage does not cover this drug.
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 Invokana.
Benefits for Invokana 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: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of Actemra.
You asked the Plan to pre-approve Actemra. You say that you are appealing based on medical necessity. The Plan denied your request. The Plan says the denial of authorization for Actemra is correct, because the Plan requires a trial of Simponi Aria before it will approve Actemra.
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 Actemra. Our reviewer says that the enrollee does not meet the Medicare criteria for a step therapy exception for Actemra. Our physician reviewer found the documentation does support that the enrollee has tried and failed treatment with Remicade. However, the documentation does not support prior treatment, contraindication, or intolerance to Simponi Aria. The documentation does not support that Simponi Aria 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 Actemra have not been met. Therefore, we decided that the Plan does not have to pre-approve use of Actemra.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Opdivo.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 that the services are not medically necessary.The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are medically necessary. Our physician reviewer found the enrollee has a left renal mass with lung nodules. There is significant iron deficiency anemia. He is not likely to do well with more aggressive therapy. Opdivo and ipilumumab is first-line therapy for renal cell carcinoma. Observational studies have shown that single agent Opdivo is more efficacious than standard VEGF inhibitors and likely better tolerated. The Opdivo is reasonable and medically necessary and safe and effective for the enrollee at this time.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have been met.Therefore, we decided that the Plan has to pre-approve Opdivo.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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient mental health care from April 28, 2020 on.
You asked the Plan to pre-approve continued inpatient mental health care. You say that this is medically necessary. The Plan denied your request. The Plan says you are not a danger to yourself or others.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 continued inpatient mental health care. Our reviewer says that the requested inpatient care is not medically necessary. Our physician reviewer found the records provided do not show that it was not expected that you would improve in a reasonable period of time for the dates in question as you did not have suicidal or homicidal ideation noted and did not have overt hallucinations. You were not showing any acute threats to safety. It does not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the dates the Plan has approved as you did not have dangerousness to 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 continued inpatient mental health care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued inpatient mental health care from April 28, 2020 on.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health skilled nursing services 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 the records do not support the need for a skilled nurse to make more visits.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 the enrollee does not require skilled nursing services to safely and effectively provide medically necessary and reasonable treatment. The enrollee does not have complex wound care, new enteral feedings or other SN need. The enrollee was educated in safely and management of her conditions which are chronic and stable. Her needs do not requires skilled nursing level care. Skilled nursing services are not required to effectively provide treatment, care, and/or services in order to improve the enrollee's condition, or to establish/perform a maintenance program to maintain the enrollee's condition and/or prevent deterioration. The request for skilled nursing visits is not 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 the services have not been met. Therefore, we decided that the Plan does not have to pre-approve home health skilled nursing services for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan.
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 PET 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has bilateral inguinal lymphadenopathy and weight loss. His symptoms are new since imaging in February of 2020. Computed tomography (CT) would be the first diagnostic test, given there is no cancer diagnosis and it is being determined if the nodes are clinically significant. The PET scan is therefore not reasonable or medically necessary at this time. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveincontinence wipes for the enrollee.You asked the Planto pre-approvethe wipes. You say that the enrollee has UTIs and incontinence.The Plandenied your request. The Plansaysthese wipes do not treat a medical condition.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 Plandoes not haveto pre-approveincontinence wipes for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvebone marrow aspiration for bone grafting.You asked the Planto pre-approvethe services. You say that this is medically necessary.The Plandenied your request. The Plansaysthere is no high level medical evidence that this procedures increases fusion rates.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 correctin 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 bone marrow aspiration remains experimental in cases of spine fusion. More research is needed.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 Plandoes not haveto pre-approvebone marrow aspiration for bone grafting.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve custodial care in an SNF.You asked the Plan to pre-approve the custodial care. You say that you would like reconsideration because you are unable to care for yourself and do not have help at home.The Plan denied your request. The Plan says custodial care is not a covered benefit.The Plan must follow Medicare rules. The rules say that custodial care is not covered.We looked at your request, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the custodial care have not been met. Specifically, you are requesting custodial care which is not covered under any condition.Therefore, we decided that the Plan does not have to pre-approve custodial care in an SNF.
Appeal type: Surgery
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 endoscopy. You say that you are concerned about your condition and the Plan's provider is unable to perform this procedure until August. 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 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 endoscopy. Our reviewer says that you do not meet the Medicare criteria for an endoscopy with an out-of-network provider. Our physician reviewer found the records show that your anemia is mild, chronic, and normocytic. The labs provided and a listing of your medical conditions do not support a medically necessary network exception for electively-scheduled endoscopy at an out-of-network 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 out-of-network endoscopy 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 endoscopy. 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: Lab
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveBRCA 1 genetic testing.You asked the Planto pre-approvethe testing. You say that this is medically necessary.The Plandenied your request. The Plansaysthere is no personal history of breast, ovarian, fallopian tube, primary peritoneal, orpancreatic cancer.The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.The test at issue in this appeal, the testing, is being requested solely for screening purposes. Medicare does not cover this test solely for screening purposes.Therefore, we decided that the Plandoes not haveto pre-approveBRCA 1 genetic testing.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.You asked the Plan to pre-approve the SNF services. You say that a SNF level of care is medically necessary.The Plan denied your request. The Plan says SNF care is not medically necessary and that the enrollee does not meet the criteria for coverage.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral medications, had stable vital signs, and had routine catheter care. The enrollee received physical therapy, speech therapy, and occupational therapy in the acute hospital. The enrollee was at a stand-by-assist to supervision-level with functional mobility, including gait to 300 feet with a rolling walker. The enrollee required varying assist with activities of daily living. The enrollee had expressive aphasia greater than receptive aphasia. There are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs, but they are not required on a daily basis. The enrollee does not meet the severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the SNF services have not been met.Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips.
You asked the Plan to pre-approve the additional routine transportation trips. You say that you require additional routine transportation trips in order to attend your dialysis appointments. You say that this is a life or death situation. The Plan denied your request. The Plan says the enrollee has exceeded the benefit limit for routine transportation trips.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 60 one-way routine transportation trips per year. We looked at your request, the records in the case file, and the rules. The records show that you have used 60 one-way routine transportation trips in the 2020 calendar year. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay fordrug testing provided on November 11, 2019.You asked the Plan to pay fordrug tests. You say that you are appealing with records.The Plan denied your request. The Plan says the denial of payment for these services is correct, because the documentation submitted does not include a valid physician order, lab requisition, or medical records for the billed test.The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific lab services is required for covered lab services. We looked at the file and Medicare rules. The documentation submitted does not include a physician order or clear intent to order the specific lab service billed on this claim. Based on this information, we decided that Medicare rules for coverage of drug tests have not been met.Therefore, we decided that the Plan does not have to pay fordrug testing provided on November 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on December 6, 2019 by an out of network (OON) provider.
You asked the Plan to pay for office visit. You say that you cannot afford to make this payment. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and authorization was not obtained.
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 pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 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. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the medical services provided on December 6, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay fordomiciliary or rest home visits (99327, P9604) and laboratory services (85025, 80053) provided on December 16, 2019 to December 23, 2019 by an out of network (OON) provider.You asked the Plan to pay forOON domiciliary or rest home visits and laboratory services. You say that you were told these providers would be covered.The Plan denied your request. The Plan says these services were not authorized.Medicare rules say that plans can require enrollees to getcare from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.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. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay fordomiciliary or rest home visits (99327, P9604) and laboratory services (85025, 80053) provided on December 16, 2019 to December 23, 2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a dental extraction to be performed by an oral surgeon.
You asked the Plan to pre-approve the dental services. You say that your tooth is broken below the gum line and is cutting your cheek. The Plan denied your request. The Plan says the rules have not been met.
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. This provider is an oral surgeon and not covered by the Plan. Your EOC states, services must be performed by a participating general dentist. Therefore, we decided that the Plan does not have to pre-approve a dental extraction to be performed by an oral surgeon.