Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a rollator nitro. 
 
You asked the Plan to pre-approve a rollator nitro. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the requested device is not covered. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have a rollator. Your current rollator serves the same purpose as a rollator nitro. Also, 
your current rollator is less than five years old. Therefore, we decided that the Plan does not have to pre-
approve a rollator nitro.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 3 additional dental crowns, 3 additional dental fillings, 
gingival irrigation, and core buildup services. 
 
You asked the Plan to pre-approve crowns, fillings, gingival irrigation, and core buildup. You say that you are 
in pain and are unable to eat. The Plan denied your request. The Plan says the denial of authorization for these 
services is correct, because the benefits for crowns and fillings have already been exhausted and the Plan does 
not cover gingival irrigation and core build-ups. 
 
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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the benefit for crowns and fillings has 
already been exhausted and gingival irrigation and core build-ups are not covered by the Plan's dental benefits. 
Therefore, we decided that the Plan does not have to pre-approve 3 additional dental crowns, 3 additional 
dental fillings, gingival irrigation, and core buildup services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 
You asked the Plan to pre-approve Euflexxa. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the requested drug does not meet step therapy criteria. 
 
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 Euflexxa. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee is noted to have osteoarthritis. The health plan requires that other forms of hyaluronic acid 
injections be used. There is no evidence that the enrollee is allergic to or intolerant of these other forms of 
hyaluronic acid. There is no evidence that the enrollee has tried and not responded to these other forms of 
hyaluronic acid injections. There is no documentation as to why these other forms of hyaluronic acid would not 
be expected to be safe and effective for the enrollee. Therefore, the enrollee does not meet criteria for the 
requested drug. 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral to an out-of-network vascular surgeon. 
 
You asked the Plan to pre-approve these services. You say that this provider performed your previous surgery. 
The Plan denied your request. The Plan says the services are available from network providers. 
 
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 referral to an out-of-network vascular surgeon.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda. 
 
You asked the Plan to pre-approve Keytruda. You say that the requested Keytruda is medically necessary. The 
Plan denied your request. The Plan says the requested Keytruda is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Keytruda. Our reviewer says that the 
requested Keytruda is not medically necessary. Our physician reviewer found the enrollee is diagnosed with 
stage 4 lung cancer. The requested use of Keytruda is not FDA-approved for the enrollee's diagnosis. PD-L1 
negative and TMB-high indication is after progression without other treatment options. The use of Keytruda is 
not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved 
medical journal for the enrollee's diagnosis.
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the implantation of a CardioMEMS device (33289).
You asked the Plan to pre-approve the implantation of a CardioMEMS device. You say that this is medically necessary. The Plan denied your request. The Plan says this is considered 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 implantation of a CardioMEMS device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the efficacy of the CardioMEMS heart failure system remains uncertain at this time. Further clinical study is needed to determine that this device is safe and effective. 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 implantation of a CardioMEMS device have not been met. Therefore, we decided that the Plan does not have to pre-approve the implantation of a CardioMEMS device (33289).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide additional payment for the prophylaxis (D1110), Periodic oral evaluation (D0120), and four bitewing radiographic images (D0274).

You asked the Plan to provide additional payment for the dental cleaning, evaluation, and bitewing x-rays. You say that you should have be told ahead of time that the provider was OON. The Plan denied your request. The Plan says when you receive services from an OON provider, the provider is allowed to charge the difference between the Plan's allowed amount and the total cost billed.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the dental cleaning, evaluation and bitewing x-rays when the services are medically necessary and reasonable.

We looked at the file and Medicare rules. The Plan provided documentation that they paid the entire allowed amount for the services. Since you used an OON provider, the provider is allowed to bill for the difference between the full amount billed and the Plan's allowed amount for the service. Based on this information, we decided that the Plan does not have to provide additional payment for the prophylaxis (D1110), Periodic oral evaluation (D0120), and four bitewing radiographic images (D0274).
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 you believe the enrollee meets criteria for IRF. The 
Plan denied your request. The Plan says the denial of authorization for IRF service is correct. 
 
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. Our 
physician reviewer found the complexity of the enrollee's nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
record supports a need for physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a 
reasonable expectation that the enrollee will be able to fully participate in - and benefit from - the intensive 
rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Procrit. 
 
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 step therapy requirement is 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has anemia of chronic 
kidney disease. She has not tried and failed the Plan's required drug, epoetin alfa-epbx. The records do not 
show that the required drug would be contraindicated or less effective; therefore, Procrit is 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 Procrit.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of a CardioMEMS device (C2624, 33289).
You asked the Plan to pre-approve the insertion of a CardioMEMS device. You say that this is medically necessary. The Plan denied your request. The Plan says this is experimental.
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 insertion of a CardioMEMS device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the efficacy of the CardioMEMS heart failure system remains uncertain at this time. Further clinical study is needed to determine that this device is safe and effective. 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 insertion of a CardioMEMS device have not been met. Therefore, we decided that the Plan does not have to pre-approve the insertion of a CardioMEMS device (C2624, 33289).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional acupuncture visits. 
 
You asked the Plan to pre-approve the additional visits. You say that you do not want to struggle any longer. 
The Plan denied your request. The Plan says only 20 visits are covered. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the 
Plan?s rules apply in this case.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, twenty visits have already been received in the past 
year. Therefore, we decided that the Plan does not have to pre-approve additional acupuncture visits.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that inpatient skilled nursing facility care is medically 
necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for 
coverage of inpatient skilled nursing facility care. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section 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 
inpatient skilled nursing facility care is not medically necessary. Our physician reviewer found that the enrollee 
continues to have labile blood glucose and hypoxia. The enrollee does not require skilled nursing and/or skilled 
therapy services on a daily basis in a skilled nursing facility. She requires further services and stabilization in 
the hospital. When she is ready to discharge she can receive further rehabilitation services at a lower level of 
care. Although further rehabilitation services would be appropriate to improve function, as a practical matter, 
the intermittent skilled services can be provided at a lower level of care than a skilled nursing facility. The 
enrollee does not have any parental medication, complex wound care, or nutrition given via a feeding tube. Her 
physical function is at or near her baseline and she can receive services at a lower level of care. Therefore, 
admission to a SNF for inpatient skilled rehabilitation services 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve inpatient skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a back brace (L0650) provided on November 5, 2020.
You asked the Plan to pay for the back brace. You say that you would like reconsideration because the back brace is medically necessary. The Plan denied your request. The Plan says Medicare prohibits unsolicited telemarketing calls to members by providers.
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 pay for the back brace. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the provided medical records do not indicate that a back brace was recommended. The documentation does not include an assessment by the ordering physician.
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 back brace have not been met. Therefore, we decided that the Plan does not have to pay for a back brace (L0650) provided on November 5, 2020.
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 IRF admission is medically necessary. The Plan 
denied your request. The Plan says the enrollee's needs can be met at a different level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described 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. Our 
physician reviewer found 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 needs can be met at an alternate 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 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: 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 IRF admission is medically necessary. The Plan 
denied your request. The Plan says your needs can be met at a different level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described 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. Our 
physician reviewer found based on the medical records provided 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 may require skilled physical therapy and occupational therapy but based on the 
medical records provided It is not clear you would be able to fully benefit and/or participate in an IRF 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 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: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that LTACH Admission is medically necessary. The Plan denied your request. The Plan says the enrollee can receive same services at the current level of care.

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. Our physician reviewer found the documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan. 

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.