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

We decided that the Plan does not have to pre-approve use of Euflexxa.
You asked the Plan to pre-approve Euflexxa. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of authorization for Euflexxa is correct, because the Plan requires a trial of Orthovisc and Monovisc before it will approve Euflexxa.
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 enrollee does not meet the Medicare criteria for a step therapy exception for Euflexxa. Our physician reviewer found the enrollee has not tried and failed the Plan's preferred drugs of Orthovisc and Monovisc. The documentation does not support that these preferred drugs would likely be less effective and/or have adverse effects for the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have to pre-approve use of Euflexxa.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ilumya 100 mg/ml syringe (J3245).

You asked the Plan to pre-approve Ilumya. You say that this drug is medically necessary. The Plan denied your
request. The Plan says step therapy criteria has 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 Ilumya. Our reviewer says that this
drug is not medically necessary and reasonable. Our physician reviewer found the enrollee is a 66-year-old
male with a history of psoriasis. His provider has requested Illumya. The Plan requires a trial of Remicade or
Inflectra and Stelara they will approve the requested drug. In this case, the patient has 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 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 Ilumya have not been met. Therefore, we decided that the Plan does not have to
pre-approve Ilumya 100 mg/ml syringe (J3245).
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 need additional trips because of medical appointments. The Plan denied your request. The Plan says your request exceeds the number of trips listed in your EOC.

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.

We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met. The 51st trip and beyond is not a covered benefit. The health plan contract says you are covered for fifty (50) one-way, non-emergency trips to plan-approved locations within the plan service area. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for frames (V2020), and lenses (V2203)
received on January 12, 2021.

You asked the Plan to pay an additional amount for frames and lenses. You say that you would like the Plan to
pay an additional amount for the items. The Plan denied your request. The Plan says the benefits were applied
correctly. The benefit allowance of $300 was applied to the purchase leaving a member responsibility of $179.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in
this case. The Plan covers these services up to a $300 allowance, then the member is responsible for paying the
difference.

We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for
coverage of frames and lenses have not been met. Specifically, the record shows that the member had
exhausted their eyewear benefit maximum of $300 and are therefore, responsible for paying the remainder of
$179. Therefore, we decided that the Plan does not have to pay an additional amount for frames (V2020), and
lenses (V2203) received on January 12, 2021.
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 current medical conditions require daily oversight by a physician and therapist. The Plan denied your request. The Plan says the denial of authorization for IRF care 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 14 additional physical therapy visits.
You asked the Plan to pre-approve the additional visits. You say that this is medically necessary. The Plan
denied your request. The Plan says this is not medically necessary beyond the four approved visits to establish
a home exercise program.
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 additional 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 additional requested therapy is not generally accepted as specific
and effective therapy for your condition beyond what was approved by the health plan. You have had extensive
prior therapy for this condition and the records do not demonstrate that the unique skills of a professional
therapist are required to safely and effectively provide treatment, that the services can be safely and effectively
performed only by a therapist, or by or under the supervision of a therapist. You have been authorized
additional therapy to ensure competence in a home exercise program. The requested services are not part of a
maintenance program.
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 additional visits have not been met. Therefore, we decided that the Plan
does not have to pre-approve 14 additional physical therapy visits.
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 care is medically necessary. The Plan denied your request. The Plan says rules for LTACH care have not been met.
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 patient is a 79-year-old male who was admitted to the current acute care hospital who subsequently has received hemodialysis and mechanical ventilation. The patient appears to be improving and only requires additional short-term acute care services and care which can safely be received at the current acute care facility. The patient does not require services at the LTACH that are not already available at the current facility. Transfer to a lower level of care may be considered when treatment has completed. 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.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the SNF care provided from July 31, 2020, to August 22, 2020.
You asked the Plan to waive the copayment for SNF care. You say that you were not allowed to return to the assisted living facility because you did not have a COVID test 72 hours prior, which was not your fault. The Plan denied your request. The Plan says the copayment amount you are being charged 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 you must pay a $0 copayment per day for days 1 to 20, and a $178 copayment per day for days 21 to 100 for Skilled Nursing Facility (SNF) care. This SNF stay lasted 22 days, resulting in a total copayment amount of $356. You have been asked to pay a $0 copayment per day for days 1 to 20, and a $178 copayment per day for days 21 to 100 for SNF care. SNF care falls within the Skilled Nursing Facility (SNF) care 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 does not have to waive the copayment for the SNF care provided from July 31, 2020, to August 22, 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 longer it takes for rehabilitation, the less likely the enrollee is to regain functional use. The Plan denied your request. The Plan says the denial of authorization for IRF care 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 this 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: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the abdominal aortic screening you received on December 4,
2020.
You asked the Plan to pay for the screening. The Plan denied your request. The Plan says the benefit limit was
exceeded.
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 $0
copayment for a one-time Abdominal aortic aneurysm screening ultrasound for people at risk.
Review of the file shows that you were provided an abdominal aortic screening on December 4, 2020. This
service is only covered one time. The records show that you were also provided this screening on February 6,
2018. The requested screening exceeds the benefit limit. This means that you have been asked to pay the
correct amount based on your contract with the Plan. Therefore, we decided that the Plan does not have to pay
for the abdominal aortic screening you received on December 4, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the prosthetics provided by an out-of-network provider on April 20, 2020.
You asked the Plan to pay for the prosthetics. You say that these were ordered when the enrollee had Medicare. You say that the charges should be considered for payment. The Plan denied your request. The Plan says these services required 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 had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the prosthetics provided by an out-of-network provider on April 20, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient psychiatric care from April 23, 2021, forward.
You asked the Plan to pre-approve continued inpatient psychiatric care. You say that continued inpatient psychiatric care is medically necessary. The Plan denied your request. The Plan says inpatient psychiatric care is not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve continued inpatient psychiatric care. Our reviewer says that the requested inpatient care is not medically reasonable and necessary. Our physician reviewer found you are a 31-year-old male was admitted to the acute inpatient psychiatric hospitalization on April 14, 2021. The Plan has agreed to cover this patient from April 14, 2021, until April 22, 2021, but has denied coverage based on medical necessity from April 23, 2021, forward. You did not require inpatient mental health treatment beyond the dates in question as you were not a danger to yourself or others and did not have any auditory or visual hallucinations or behavioral issues. It did not appear that active treatment was taking place beyond the date in question. It did not appear that the services for the dates in question were reasonably expected or medically necessary to improve your condition or for the purpose of diagnosis. Based upon review the records provided, you do not meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in question of April 23, 2021, forward and could have been treated in a lesser restrictive setting as you were not showing any suicidal or homicidal ideation, auditory or visual hallucinations and was not showing any aggressive behaviors being cooperative and compliant.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued inpatient psychiatric care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued inpatient psychiatric care from April 23, 2021, forward.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a clinic visit (G0463) provided on June 5, 2020.
You asked the Plan to waive the copayment for a clinic visit. You say that you were told you would not have a copayment. The Plan denied your request. The Plan says this processed 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 $50 copayment for physician specialist services, including urgently needed services. You have been asked to pay a $50 copayment for a clinic visit. 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 a clinic visit (G0463) provided on June 5, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the CxBladder testing provided on October 9, 2020.
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered service.
The Plan must follow Medicare rules. Medicare rules say that LCD L35396 provides a list of covered molecular bladder tests. We looked at the file and Medicare rules. Per LCD L35396, the CxBladder test is not a covered molecular test. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay for the CxBladder testing provided on October 9, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for critical care (99291) provided on September 8, 2020.
You asked the Plan to pay for critical care. You say that this is supported in the records. The Plan denied your request. The Plan says this is not documented.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 99291 is critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes. We find that CPT code 99291 is not supported in the medical record. Specifically, the submitted medical records do not include documentation of the time spent on critical care. Based on this information, we decided that Medicare rules for coverage of critical care have not been met. Therefore, we decided that the Plan does not have to pay for critical care (99291) provided on September 8, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Herceptin (J9355).
You asked the Plan to pre-approve Herceptin. You say that this drug is medically necessary for the enrollee's
condition. The Plan denied your request. The Plan says ovarian cancer is not an approved indication for the
requested medication.
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 Herceptin. Our reviewer says that the
requested drug is not medically reasonable and necessary. Our physician reviewer found the enrollee has been
diagnosed with ovarian cancer with germ line instability. In this case, Herceptin is not FDA-approved for the
enrollee's diagnosis. In addition, there is no compendia basis nor literature support to approve a Herceptin
based regimen in ovarian cancer.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Herceptin have not been met. Therefore, we decided that the Plan does not have
to pre-approve Herceptin (J9355).