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

We decided that the Plan has to pre-approve an epidural spinal injection for the enrollee.
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your
request. The Plan says that there is no evidence of a trial and failure of active conservative therapy.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item
or service, then that item or service will be covered when it is 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 the injection. Our reviewer says that the
requested injection is considered medically reasonable and necessary in this case. Our physician reviewer
found the enrollee has tried and failed conservative therapy, which meets the standard criteria for this injection.
The requested procedure is medically 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 injection have been met. Therefore, we decided that the Plan has to preapprove
an epidural spinal injection for the enrollee.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve endovenous ablation to be provided by an out of network (OON) provider.You asked the Plan to pre-approve endovenous ablation. You say that this is a continuity of care since January 22, 2020.The Plan denied your request. The Plan says there are multiple in-network providers available for these services.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 endovenous ablation 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 upper extremity myoelectric orthosis (L8702).
You asked the Plan to pre-approve the orthosis. You say that please approve this medically necessary care for the enrollee who otherwise has no arm function. The Plan denied your request. The Plan says this device is considered experimental or investigational.
The Plan must follow Medicare rules. The rules also say that experimental and investigational devices are not covered. Based on this information, we decided that Medicare rules for coverage of the orthosis have not been met. Therefore, we decided that the Plan does not have to pre-approve upper extremity myoelectric orthosis (L8702).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xopenex Hfa Aer.
You asked the Plan to pre-approve Xopenex Hfa Aer. You say that the medication is necessary. The Plan denied your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit or a separate pharmacy benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage.
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 Xopenex Hfa Aer.
Benefits for Xopenex Hfa Aer 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 pre-approve debit card for allowance for healthy food purchases or
electricity, water or phone bill payments (S9986). You asked the Plan to pre-approve debit card for allowance for healthy food purchases or electricity, water or phone bill payments. You say that you have asthma and is requesting reconsideration of the denial for the allowance. The Plan denied your request. The Plan says the enrollee does not meet the criteria established to
receive the allowance. The Plan must follow Medicare rules. Medicare rules say that Medicare does not pay for healthy food
purchases or electricity, water or phone bill payments. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan pays for this only when you have one or more comorbid and medically complex chronic conditions that are life-threatening or significantly limit your health or general functions. In addition, you must have a high risk of hospitalization or other adverse health outcomes and must require intensive care coordination. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of debit card for allowance for healthy food purchases or electricity, water or phone bill payments have not been met. Therefore, we decided that the Plan does not have to pre-approve debit card for allowance for healthy food purchases or electricity, water or phone bill payments (S9986).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a mammogram (77067) to be provided by the facility.
You asked the Plan to pre-approve the mammogram. You say that the service is medically necessary. The Plan denied your request. The Plan says there are network providers who can perform the service at issue.
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 a mammogram (77067) to be provided by the facility.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the cervical spine for the enrollee.
You asked the Plan to pre-approve the MRI. You say that a cervical MRI is recommended given the enrollee's balance problems and short-term memory difficulty. The Plan denied your request. The Plan says there is no evidence of conservative treatment or abnormal exam findings.
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 the MRI. Our physician reviewer found that the enrollee has a history of short term memory loss, balance problem and a gait problem. Based on the medical records provided, the cervical spine MRI is not medically reasonable and necessary to treat 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 the MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the cervical spine for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Computed Tomography angiography (CTA) scan of the chest.You asked the Plan to pre-approveCTA scan. You say that you are appealing with medical records.The Plan denied your request. The Plan says the denial of authorization for this service is correct, because a repeat scan is not medically necessary unless there is clinical evidence pointing to recurrent embolism or development of pulmonary hypertension.The Plan must follow Medicare rules. Medicare rules say that CT 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 CTA scan. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested CTA scan. Our physician reviewer found the reason for this requested CTA was for comparison to see if the enrollee's embolus has disappeared. Greater than 80% of pulmonary embolism is resolved within 30 days. There is no medical need to repeat a CTA unless there is clinical evidence pointing to recurrent embolism or development or pulmonary hypertension. Therefore, the requested CTA scan is not medically reasonable and necessary at this time.We looked at this physician's review, the file, and Medicare rules. Based onthis information, we decided that Medicare rules for coverage of CTA scan have not been met.Therefore, we decided that the Plan does not have to pre-approvea Computed Tomography angiography (CTA) scan of the chest.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve continued skilled nursing facility (SNF) services beyond March 22, 2020 for the enrollee. You asked the Plan to pre-approve SNF care. You say that you disagree with the denial. The Plan denied your request. The Plan says that the continued services are not medically necessary. 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 the continued services are medically necessary. Our physician reviewer found the enrollee was admitted to the SNF on March 9, 2020 and has a new diagnosis of c. difficile diarrhea. He is being monitored for stools. He received physical and occupational therapy in the SNF and needs contact guard assist with functional mobility, including gait to 150 feet with a rolling walker. He needs varied assist with activities of daily living. He has skilled nursing needs to monitor his stools, hydration status, and c. difficile infection. He needs skilled nursing on a daily basis. He has skilled therapy needs and requires skilled therapy on a daily basis. As a practical matter, the enrollee requires the necessary services on an inpatient basis at the SNF level of 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 SNF care have been met. The Plan must continue coverage for the SNF skilled service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve continued skilled nursing facility (SNF) services beyond March 22, 2020 for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve physician services. You say that you would like approval to see a physician. The Plan denied your request. The Plan says you have been approved to see multiple physicians.
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 physician services 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 incontinence supplies, wipes (W0137).
You asked the Plan to pre-approve incontinence supplies. You say that these items were previously covered and you do not understand why all of a sudden they've gotten denied. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that 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 Plan does not have to pre-approve incontinence supplies, wipes (W0137).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CT scan of the lower back. You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your request. The Plan says the information does not show any signs or symptoms, such as significant motor weakness, infection, or planned surgery. The Plan must follow Medicare rules. Medicare rules say that CT 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 the scan. Our reviewer says that the requested scan is not medically reasonable or necessary. Our physician reviewer found there are no plain film results of the lumbar spine in the records. There is no red flag to mandate immediate imaging in the records. Medical necessity for CT of the lumbar spine has not been established in the records provided. 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 scan have not been met. Therefore, we decided that the Plan does not have to pre-approve CT scan of the lower back.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Repatha Sureclick for enrollee.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 self-administered drugs are not covered.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-approveRepatha Sureclick for enrollee.Benefits for these services 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bi-level positive airway pressure machine (BiPap) for the enrollee.
You asked the Plan to pre-approve the machine. You say that this is medically necessary. The Plan denied your request. The Plan says the medical records did not show if the enrollee was awake, sleeping or immediately awakened when the blood gas studies were done. 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 machine. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no sleep study or PAP titration data. The enrollee's diagnosis requires confirmation, and he needs a PAP titration study. 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 machine have not been met. Therefore, we decided that the Plan does not have to pre-approve a bi-level positive airway pressure machine (BiPap) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician's services for a second opinion to be provided by the university.
You asked the Plan to pre-approve the physician's services for a second opinion. You say that you are afraid to walk without falling. You say you have had three MRI's and neck surgery and your doctor in Toledo said he cannot do anything more for you. The Plan denied your request. The Plan says there are in-network providers that are available for you to see.
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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve physician's services for a second opinion to be provided by the university.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approve the acute inpatient admission requested on March 18, 2020. You asked the Plan to pre-approve the inpatient admission. You say that this admission was warranted and should have been approved. The Plan denied your request. The Plan says that the enrollee's condition could be managed as outpatient observation. The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 inpatient admission. Our reviewer says that the documentation supports that the criteria for inpatient admission are met in this case. Our physician reviewer found the enrollee presented to the ED of an outside facility with sudden onset slurred speech, right sided facial droop and weakness. He was admitted to the current facility for post-TPA monitoring in the neuro-ICU. He was initially admitted to the ICU but stabilized and was transferred to the medical floor. The review has determined that the record showed that at the time of the request for inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier ED and/or observation care) would span two midnights. 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 inpatient admission have been met. Therefore, we decided that the Plan has to pre-approve the acute inpatient admission requested on March 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor for the enrollee.
You asked the Plan to pre-approve the monitor. You say that this is medically necessary, as the enrollee is a good candidate for this monitor. The Plan denied your request. The Plan says this is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered only when they are medically reasonable and necessary and replace a blood glucose monitor. 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 monitor. Our reviewer says that the requested monitor is not medically reasonable or necessary. Our physician reviewer found there is no specific guidance documented as to what insulin dose adjustment would be recommended based on the continuous glucose monitoring results. The coverage criteria has not been met. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician's services for a second opinion to be provided by the physician.
You asked the Plan to pre-approve the physician's services for a second opinion. You say that you believe it is best to get an unbiased second opinion outside of the Plan's network of providers. The Plan denied your request. The Plan says you must see a provider that is in-network.
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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve physician's services for a second opinion to be provided by the physician.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician's services to be provided for enrollee.You asked the Plan to pre-approve the physician's services. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan. 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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve physician's services to be provided for enrollee