Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 4 occupational therapy visits.
You asked the Plan to pre-approve the 4 occupational therapy visits. You say that the occupational therapy visits are medically necessary. The Plan denied your request. The Plan says the occupational therapy visits are not medically
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 4 occupational therapy visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the enrollee and caregiver were instructed how to use the sling and HEP and that the member was able to toilet with contact guard and dress the upper body. Our physician reviewer found that the member was able bathe in a shower or tub with intermittent assistance, get to and from the toilet independently and is interdependent for eating. Our physician reviewer found that the member had met all treatment goals and is at modified independence for functional mobility. 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 4 occupational therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 4 occupational therapy visits.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvefacet joint radiofrequency ablation (RFA).You asked the Planto pre-approvethe injection. You say that this is medically necessary.The Plandenied your request. The Plansaysthe clinical information provided does not describe two successful medial branch blocks, and therefore, the requested procedure is not indicated at this time.The Plan must follow Medicare rules. Medicare rules say that radiofrequency ablation is covered after two sets of successful medial branch blocks.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 services are not considered medically reasonable and necessary in this case. Our physician reviewer found the standard of care requires two sets of medial branch blocks to confirm the pain generator before proceeding to RFA. Only one set is documented, therefore, the request is considered 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 injection have not been met.Therefore, we decided that the Plandoes not haveto pre-approvefacet joint radiofrequency ablation (RFA).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea MyoPro Elbow-wrist-hand-finger orthosis (L8702).You asked the Plan to pre-approveMyoPro Elbow-wrist-hand-finger orthosis. The Plan denied your request. The Plan says there is insufficient published evidence to assess the impact on health outcomes or patient management associated with the use of the MyoPro Orthosis for upper extremity paralysis/paresis after stroke.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 MyoProElbow-wrist-hand-finger orthosis. Our reviewer says that this item is not medically necessary for the patient per the Social Security Act, Section 1862(a)(1)(A). Our physician reviewer found The MyoPro Orthosis is not known to be effective, based on scientific evidence, professional standards and expert opinion, in improving health outcomes. The MyoPro is not in widespread use, for hemiparesis from stroke, based on scientific evidence. There is insufficient evidence in the literature that the MyoPro Orthosis will improve the long term outcomes for this patient's stroke related hemiparesis, improve his hemiparetic arm function, or be safe for long term use.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of MyoPro Elbow-wrist-hand-finger orthosis have not been met.Therefore, we decided that the Plan does not have to pre-approvea MyoPro Elbow-wrist-hand-finger orthosis (L8702).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services for an eye exam provided on July 8, 2019.
You asked the Plan to pay for the physician's services for an eye exam. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.
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 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 physician's services for an eye exam provided on July 8, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forlab tests provided on September 19, 2019 by an out of network (OON) provider.You asked the Plan to pay forlab tests. You say that you would like this appeal approved for payment.The Plan denied your request. The Plan says the referring provider is out-of-network. The Plan says that no prior authorization was 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 forlab tests provided on September 19, 2019 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says step therapy criteria was not met.
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 drug. Our reviewer says that the requested drug does not meet the step therapy criteria. Our physician reviewer found there is no evidence of a trial and failure of zoledronic acid. The provided medical records do not indicate that the plan's required drug would likely be less effective and/or likely 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 the drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Denosumab injection (J0897).You asked the Plan to pre-approve the injection. You say that this service is medically necessary for the treatment of the member's condition. The Plandenied your request. The Plan says step therapy exception criteria have not been met.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 injection. Our reviewer says that the records do not support the enrollee has been treated with zoledronic acid. Our physician reviewer found without the support of the documentation, denosumab is not approved as step criteria is not met. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a Denosumab injection(J0897).
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for drug testing provided on October 29, 2019.
You asked the Plan to pay for drug test. You say that this testing was deemed medically necessary by the
ordering physician, and it was not the responsibility of your laboratory to create a treatment plan or have any
contact with the enrollee. The Plan denied your request. The Plan says that the denial of payment for this
service is correct, because this test exceeds the maximum covered frequency of 18 tests per year.
The Plan must follow Medicare rules. Medicare rules say that the frequency of presumptive urinary drug
testing may be limited to 156 times per year for enrollees with 0 to 90 consecutive days of abstinence or 36
times per day for enrollees with more than 90 consecutive days of abstinence.
We looked at the file and Medicare rules. Our review of the rules did not reveal a limitation of 18 tests per year
for these services, as cited by the Plan. The Plan has not shown that this test exceeded the frequency limitation
for presumptive urinary drug testing as cited above in the LCD. Based on this information, we decided that
Medicare rules for coverage of drug test have been met. Therefore, we decided that the Plan has to pay for drug
testing provided on October 29, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveTrulicity for the enrollee.You asked the Plan to pre-approvethis drug. You say that this is medicallynecessary.The Plan denied your request. The Plan says that 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-approveTrulicity for the enrollee.Benefits for this drugmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on December 5, 2019 by an out of network (OON) provider.
You asked the Plan to pay for lab work. You say that you would like this appeal reprocessed and approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that there are 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 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 lab work provided on December 5, 2019 by an out of network (OON) provider.
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 the enrollee's condition would be appropriate for rehab in the acute hospital setting with intensive therapy. The Plan denied your request. The Plan says the enrollee has no acute medical issues and is not likely to participate in three hours of daily therapy.
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 enrollee was admitted on 2/11 with acute on chronic heart failure, shortness of breath, and swelling of the legs. She has had several admissions for heart failure over the past year. A repeat echocardiogram performed revealing worsening EF of 15-20% from 20-25% with global severe hypokinesis; grade 3 diastolic dysfunction and elevated left atrial pressure. She underwent LVAD placement on 2/24. Based on review of available records, the enrollee does not meet criteria for coverage for an IRF admission. The patient is generally medically stable, with an LVD for cardiac failure and cardiac debility but high functional level and there is no evidence of medical issues that require monitoring by an inpatient PMR physician three times per week or need for acute rehab nursing care. While she may benefit from continuing PT and OT, there is no evidence of need for an intensive therapy program with therapy 3 hours per day with frequent rehab physician oversight and an interdisciplinary approach to rehabilitation care at the current level of requiring only CGA and walking 300 feet. She needs cardiology and LVAD team monitoring.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve anesthesia for percutaneous image-guided procedures on the spine and spinal cord.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says there are contracted providers available, and there is no documentation provided showing the medical necessity for this anesthesia.
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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no indication for an anesthesia provider as the patient does not have morbid obesity, obstructive sleep apnea, a mental disorder that precludes cooperation, or spasticity. There is also no indication for an out of network provider as this is an elective case where in network providers are available. The request 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 anesthesia for percutaneous image-guided procedures on the spine and spinal cord.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Motegrity 2mg tablet medication.
You asked the Plan to pre-approve this medication. You say that this medication is medically necessary for the enrollee as she has been diagnosed with chronic idiopathic constipation. The Plan denied your request. The Plan says this medication is not a covered benefit under the enrollee's contractual policy.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drug requested here is not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve the Motegrity 2mg tablet medication.
Benefits for this medication 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic manipulative treatment (98940) provided on July 26, 2019.
You asked the Plan to pay for the chiropractic manipulative treatment. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says payment for this service is not allowed because it is not appropriate for the diagnosis billed.
The Plan must follow Medicare rules. Medicare rules say that the level of the subluxation must be specified on the claim and must be listed as the primary diagnosis. The neuromusculoskeletal condition necessitating the treatment must be listed as the secondary diagnosis. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the chiropractic manipulative treatment have not been met. Specifically, the level of subluxation has not been specified and the claim does not include a secondary diagnosis code to show the neuromuscular condition that necessitated the treatment. Therefore, we decided that the Plan does not have to pay for chiropractic manipulative treatment (98940) provided on July 26, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Synvisc 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 preferred viscosupplements are Orthovisc and Monovisc and don't require
prior authorization.
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 injection. Our reviewer says that the
requested injection is not medically reasonable or necessary, and does not meet the step therapy criteria. Our
physician reviewer found there is no indication that the enrollee has tried and failed Orthovisc and Monovisc.
The provided medical records do not indicate that the plan's required drugs would likely be less effective and/or
likely 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 the injection have not been met. Therefore, we decided that the Plan does not
have to pre-approve a Synvisc injection for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on October 3, 2019.
You asked the Plan to waive the copayment for the office visit. You say that you called the Plan for an in network rheumatologist. You say that you were only charged a $35 copayment. The Plan denied your request. The Plan says the copayment was applied correctly. 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 you must pay a $65 copayment for provider and professional services at an out-of-network specialist's office. You have been asked to pay a $65 copayment for the office visit. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The records show that the provider is out-of-network. 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 does not have to waive the copayment for the office visit provided on October 3, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found this enrollee does not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment in a SNF. The enrollee does not have a tracheostomy tube, enteral feedings, complex wound care or other SNF level skilled nursing need. This enrollee's functional status does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist required to safely and effectively provide medically necessary and reasonable treatment. The enrollee does not require these skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis". As a practical matter this enrollee does not require the necessary services on 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.