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

We decided that the Plan does not have to pre-approve Gel-One, a hyaluronan derivative (CPT code J7326).

You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied your request. The Plan says your doctor does not document that you have tried and failed OrthoVisc, SynVisc, and/or SynVisc-One or that you are unable to tolerate either OrthoVisc, SynVisc, and/or SynVisc-One.

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 medication. Our physician reviewer found the Plan requires a trial of drug OrthoVisc, SynVisc, and/or SynVisc-One before they will approve the requested drug. In this case, you have not tried and failed the required drug(s). There is no documentation provided indicating that the Plan's required drug(s) would likely be less effective and/or likely have adverse effects for you.

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 medication have not been met. Therefore, we decided that the Plan does not have to pre-approve Gel-One, a hyaluronan derivative (CPT code J7326).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the MyoPro Motion G orthotic device for the enrollee.

You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says medical studies have not proven that this device is helpful for treatment of the health problem.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has left hemiplegia from strokes. The medical records submitted from the prescribing physician do not support the medical reasonableness and necessity of the order as written. 

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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the MyoPro Motion G orthotic device for the enrollee.
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 these services are medically necessary. The Plan denied your request. The Plan says that you cannot benefit from and tolerate 3 hours of intensive therapy 5 days a week due to continued need for Intensive Care Unit level 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 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. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for anemia and gastrointestinal bleeding. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. You do 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 you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your 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.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Repatha SureClick for the enrollee.

You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your request. The Plan says that this is not covered under Part B.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Repatha SureClick for the enrollee.

Benefits for this drug may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
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 member needs continued therapy to regain baseline function to safely return home. The Plan denied your request. The Plan says that the enrollee can safely receive the services needed, in other settings.

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. The enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at a lower level of care. 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Meibomian gland procedure using the TearCare system for the enrollee.

You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied your request. The Plan says this is considered experimental and investigational.

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 procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the record indicates the enrollee has keratoconjunctivitis sicca with symptoms of dry eye disease. There is insufficient literature to support the requested service as not experimental and investigational. The records do not support the medical necessity and reasonableness of the requested service as defined by Medicare rules. 

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 procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the Meibomian gland procedure using the TearCare system for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan reimbursed you correctly for your out-of-network provider visit on December 11,
2020.

You asked the Plan for reimbursement for an out-of-network provider visit. You say that you disagree with the
charges. The Plan denied your request. The Plan says the reimbursement amount of $291.99 is correct.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that if you use an out-of-network
provider, your share of the costs for your covered services may be higher. The contract also says that
there is a $60 copayment for an out-of-network specialist visit.

You were reimbursed $291.99, with a $60 copayment amount for an out-of-network provider visit. This
reimbursement amount is correct as it is based on the Medicare Allowed Amount. The service at issue falls
within the visit with an out-of-network specialist benefit category. This means that you have been asked to pay
the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan reimbursed you correctly for
your out-of-network provider visit (99203, 24650, 99072) on December 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lumbar facet joint radiofrequency ablation procedure to L1-2, L2-3, and L3-4 (CPT code(s): 64635 x1, 64636 x2).

You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan denied your request. The Plan says the Medicare rules have not been 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 the services. Our physician reviewer found the medical records provided do not meet the requirements listed in the LCD for Medicare coverage. The detailed documentation is not evident regarding a second diagnostic injection having been performed. Furthermore, there is plausible evidence of radiculopathy. In such a context, medial branch nerve block has not been proven in medical literature to be an effective treatment. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines. Therefore, the request for lumbar facet joint radiofrequency ablation procedure to L1-2, L2-3, and L3-4 (64635 x1, 64636 x2) is not medically reasonable or necessary. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pre-approve lumbar facet joint radiofrequency ablation procedure to L1-2, L2-3, and L3-4 (CPT code(s): 64635 x1, 64636 x2).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex Superion spacer.
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 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 these services. Our reviewer says that
the services are not medically necessary. Our physician reviewer found the enrollee has lumbar spinal stenosis.
The requested Superion spacer is experimental in nature, as more research is needed to show safety and
efficacy. The services are therefore 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 a Vertiflex Superion spacer.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a septoplasty procedure.
You asked the Plan to pre-approve septoplasty. You say that you are experiencing recurring sinus infections
and have polyps in her nose. The Plan denied your request. The Plan says the denial of authorization for this
service is correct, because this septoplasty 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 septoplasty. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found Computed Tomography (CT) scan revealed the septum was in the midline (not deviated) and
there were no polyps noted. Septoplasty is only approved for those with a deviated septum requiring surgery
for a specific medication condition.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of septoplasty have not been met. Therefore, we decided that the Plan does not
have to pre-approve a septoplasty procedure.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided to the enrollee on January 20, 2021 and January 27, 2021.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says this should be resubmitted with the correct bill type.

The Plan must follow Medicare rules. Medicare rules say that home health claims must be submitted with the correct bill type. 

The appropriate home health type of bill was not submitted with this case. 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 pay for home health services provided to the enrollee on January 20, 2021 and January 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on January 11, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not approved in advance.

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 had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the services provided by an out-of-network provider on January 11, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional accessories for a power wheelchair (E2300, E2311, E2313, E2377).
You asked the Plan to pre-approve the accessories. You say that this is medically necessary. The Plan denied your request. The Plan says there is no medical need to control the power options through the joystick.
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 accessories. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the E2300 is not primarily medical in nature and does not meet Medicare criteria of medical necessity. The documentation does not reveal that the enrollee requires other types of proportional input devices (e.g., mini-proportional or compact joysticks, touchpads, chin control, head control, etc.) or non-proportional input devices (e.g., sip and puff, head array, etc.). The enrollee does not need to operate 3 or more powered seating actuators through the drive control, a separate display (i.e., for alternate control devices), other electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive control), or an attendant control. The enrollee's function in the upper extremities with the ability to feed himself indicates that the enrollee can control any power options through their own individual switches. 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 accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve additional accessories for a power wheelchair (E2300, E2311, E2313, E2377).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental services provided on November 2, 2020.

You asked the Plan to pay for these dental services. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says the maximum amount allowed of $1000 was exhausted prior to this date of service. Maximus overturned the Plans denial because an appropriate Plan contract was not submitted for review. The Plan requested a reopen and provided the correct contract for review. The 2020 Plan contract shows a combined dental allowance of $1000. This benefit was exhausted on 3 previous claims that were paid prior to the date of service in question. Those claims were provided for review.

The Plan is correct in this case. Medicare does not cover dental services. In 2020, the Plan offered a maximum dental benefit payout of $1000. The records provided show this benefit was exhausted prior to the date of service in question. Therefore, we decided that the Plan does not have to pay for dental services provided on November 2, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.

You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the member is receiving appropriate in-patient acute care and does not require transfer to LTACH.

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. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH 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 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 for the enrollee.
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 additional routine transportation trips. You say that you require these services are necessary. The Plan denied your request. The Plan says that your transportation benefit has been exhausted.

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 twenty-four (24) trips per year. 

We looked at your request, the records in the case file, and the rules. 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: Drugs
Decision: Favorable

We decided that the Plan has to approve coverage for Retacrit treatments.

You asked the Plan to approve coverage for the Retacrit treatments. You say that the enrollee meets the criteria for the use of Retacrit to treat her anemia. The Plan denied your request. The Plan says that the enrollee meets criteria for this drug; however, since this enrollee is on dialysis, Retacrit is not covered.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. We find that the Plan has not provided a valid denial rationale for authorization of the use of this drug. The Plan has denied coverage for the use of this drug due to billing/payment issues. The rules cited in the Medicare rules section indicate that drugs related to ESRD are covered by Medicare Part B, though payment of these drugs is included in the payment made to the ESRD facility through the ESRD PPS. There is no evidence that this request was for separate payment from the Plan, rather the request is for authorization of coverage due to medical necessity. The Plan has indicated that medical necessity criteria are met based on laboratory testing. We find that denial of coverage based on how payment for the drug will be made is not appropriate, nor supported by the rules. Therefore, we decided that the Plan has to approve coverage for Retacrit treatments.

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.