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

We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the left shoulder.
You asked the Plan to pre-approve a CT scan. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a CT scan have not been met. Specifically, medical records were not provided for review in this case. The record shows that the Plan made multiple attempts to secure medical records, without success. Without medical records, we cannot determine if Medicare criteria are met in this case. Therefore, we decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the left shoulder.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Fluorouracil 5% cream.

You asked the Plan to pre-approve Fluorouracil. You say that this drug is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says this drug is not covered under the enrollee's medical benefit.

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 Fluorouracil 5% cream.

Benefits for Fluorouracil 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 core buildup including any pins (D2950).
You asked the Plan to pre-approve the dental services. You say that the medical records provided will show proof of medical necessity. The Plan denied your request. The Plan says this service is not listed as covered under the Plan benefits
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 requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve core buildup including any pins (D2950).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vascepa Cap.
You asked the Plan to pre-approve Vascepa Cap. You say that the enrollee has tried other supplements, so you
want the enrollee to be treated with this drug. The Plan denied your request. The Plan says this drug is not
covered under the enrollee's Medicare Part B drug benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 Vascepa Cap.
Benefits for Vascepa Cap 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 pre-approve a consultation with an out-of-provider.
You asked the Plan to pre-approve the out-of-network consultation. You say that you have two blood clots in your legs that have not gotten better. You say that you want an unbiased second opinion. The Plan denied your request. The Plan says in-network providers are available.
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 consultation with an out-of-provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan
denied your request. The Plan says this would exceed the enrollee's needs.
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 enrollee was admitted with anemia, ischemic colitis, and developed respiratory
failure. The enrollee has evidence of ongoing infection despite receiving antibiotic therapy. The medical record
does not indicate that the enrollee requires services that she is not currently receiving but that would be
available at the LTACH facility.
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 LTACH services.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Durolane (J7318).
You asked the Plan to pre-approve Durolane. You say that the requested drug is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says step therapy 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 Durolane. Our reviewer says that the requested drug is not medically reasonable and necessary. Our physician reviewer found in this case, the Plan requires a trial of Monovisc and Orthovisc before they will approve the requested drug. The patient has not tried and failed the required drug(s). There is no documentation 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 Durolane have not been met. Therefore, we decided that the Plan does not have to pre-approve Durolane (J7318).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment with Gel-One (J7326).

You asked the Plan to pre-approve Gel-One. You say that the requested drug is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for treatment with Gel-One have not been met.

The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 Gel-One. Our reviewer says that the requested drug is not medically necessary. Our physician reviewer found that there is no trial and failure documented of physical therapy for knee pain. More conservative measures for knee pain are needed. The requested injection is not needed 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 Gel-One have not been met. Therefore, we decided that the Plan does not have to pre-approve treatment with Gel-One (J7326).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xolair for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says this is not being prescribed for a medically accepted indication.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found the review indicates that there is no documentation provided indicating that the enrollee has evidence of specific allergic sensitivity confirmed by a positive skin test (i.e. prick/puncture test) or blood test (i.e. RAST) for a specific IgE or in vitro reactivity to a perennial aeroallergen AND baseline serum IgE levels between 30 IU/ml and 700 IU/ml. The review indicates that the documentation does not support that the Xolair is medically reasonable and necessary for the enrollee. The documentation does not support that the Xolair is safe and effective 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 Xolair for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a ketamine infusion for the enrollee.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says this is not indicated for a chronic migraine headache.

The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 services. Our reviewer says that Our physician reviewer found there is no evidence to date from well designed clinical studies to support the use of IV Ketamine in the use of any headache disorders. In this case the requested drug (Ketamine) has not been prescribed for a FDA approved indication or a diagnosis supported within the Medicare accepted Compendia. There is insufficient evidence within the literature to support the proposed usage of Ketamine infusions in the management of chronic migraine. The evidence on the use of IV Ketamine for headache disorders is limited to case series. There have only been two small RCTs which otherwise produced conflicting results and had methadological limitations (see Cohen et al 2018). In this setting it cannot be concluded that the requested medication would be safe and effective for this 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve a ketamine infusion for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an occlusal guard (D9945).
You asked the Plan to pre-approve the occlusal guard. You say that you need this guard because you grind your
teeth while you sleep. The Plan denied your request. The Plan says this service is not covered under your
benefit package.
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 requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an
occlusal guard (D9945).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the digital breast tomosynthesis rendered on December 28, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 77062 is not covered.
The Plan must follow Medicare rules. The rules say that a status indicator of I represents a code that is not valid for Medicare purposes. We looked at the file and Medicare rules. The file shows that billed procedure code 77062 (bilateral digital breast tomosynthesis) has a status indicator of I and is not valid for Medicare purposes. Therefore, we decided that the Plan does not have to pay for the digital breast tomosynthesis rendered on December 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve partial lower denture, cast metal framework with resin denture bases, including any conventional clasps, rests and teeth (D5214).
You asked the Plan to pre-approve the dental service. You say that you lost your bottom partial denture and was told by another representative that you would be able to get a replacement pair, but it would require prior authorization. The Plan denied your request. The Plan says the denture benefit has been exhausted.
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. This health plan contract says that this benefit is allowed once every 5 years. The records show that this benefit was already provided on April 19, 2021. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered at this time. Therefore, we decided that the Plan does not have to pre-approve partial lower denture, cast metal framework with resin denture bases, including any conventional clasps, rests and teeth (D5214).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the physical therapy to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the physical therapy. You say that the Plan does not have adequate physical therapy that meets the enrollee's needs. The Plan denied your request. The Plan says the provider is out-of-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 items/services at issue in this appeal. The record shows the enrollee is willing to start with an in network physical therapist. 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 the physical therapy to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit provided on
March 15, 2021.

You asked the Plan to waive the copayment for the specialist office visit. You say that you should not be
responsible for the copayment. The Plan denied your request. The Plan says you have been asked to pay the
correct cost-sharing amount.

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 $35
copayment for each specialist visit for Medicare-covered benefits.

You have been asked to pay a $35 copayment for the specialist office visit. The specialist office visit falls
within the "Physician/Practitioner Services, Including Doctor's Offices" benefit category. The medical record
shows you were seen for a follow-up appointment. 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 specialist office visit provided on March 15, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xopenex HFA 45 mcg inhaler for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says the requested drug is intended for patient self administration.
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 45 mcg inhaler for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an occlusal guard (D9944) to be provided by an OON dentist.
You asked the Plan to pre-approve the occlusal guard. You say that previous claims for this site have been approved. The Plan denied your request. The Plan says this plan requires services to be performed by a contracted dentist.
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 requested items or services are not covered when they are received OON. Therefore, we decided that the Plan does not have to pre-approve an occlusal guard (D9944) to be provided by an OON dentist.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory test provided by an out-of-network provider on January 4, 2021.
You asked the Plan to pay for the laboratory test. You say that the testing meets the requirements of the NCD and has been determined to be reasonable and necessary by CMS. You say that there should be a favorable resolution of the claim. The Plan denied your request. The Plan says the non-urgent services are not authorized because this provider is not a network provider with the Plan.
We decided that the Plan does not have to pay for the laboratory test provided by an out-of-network provider on January 4, 2021.
You asked the Plan to pay for the laboratory test. You say that the testing meets the requirements of the NCD and has been determined to be reasonable and necessary by CMS. You say that there should be a favorable resolution of the claim. The Plan denied your request. The Plan says the non-urgent services are not authorized because this provider is not a network provider with the Plan.
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 would benefit from more intensive rehabilitation care. The Plan denied your request. The Plan says the enrollee does not have complex medical conditions or skilled nursing needs that require the requested level of care. The enrollee does not need to be seen by a doctor who specializes in rehab three times per week or rehab that requires an intensive team approach. Based on the clinical information received, the enrollee does not meet the guidelines for IRF services. The enrollee's needs can be met at a lower 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 that 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. The enrollee does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. 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. Medically necessary services can be provided in a different 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on January 10, 2021.
You asked the Plan to pay for the ambulance services. You say that you were treated in place by the medics. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport.
The ambulance company did not provide transport services on January 10, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on January 10, 2021.