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

We decided that the Plan does not have to pre-approve Nudexta capsules.
You asked the Plan to pre-approve self-administered drugs. You say that the enrollee has been using this
medication since 2017 and it is medically necessary. The Plan denied your request. The Plan says the denial of
authorization for this drug is correct, because this drug is not covered by Medicare Part B and the Plan does not
administer the enrollee's Medicare Part D prescription drug benefits. The Plan also says that the enrollee may
receive prescription drug benefits through UFCW International.
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 Nudexta capsules.
Benefits for self-administered drugs 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.You asked the Plan to pre-approve SNF services. You say that the enrollee needs short term rehab.The Plan denied your request. The Plan says that the enrollee does not require daily skilled nursing and/or daily multidisciplinary skilled rehabilitation services.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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for SNF services.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 services have not been met.Therefore, we decided that the Plan does not have to pre-approveskilled nursing facility (SNF) services for the enrollee
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe tetanus vaccine you received on August 6, 2019.You asked the Plan to pay forthe vaccine. You say that it was recommended that you get the vaccine.The Plan denied your request. The Plan says this is not covered under your medical plan.In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccine. The Plan follows the same rules. The records do not show that you have been injured or directly exposed to any illness related to the vaccine.Therefore, we decided that the Plan does not have to pay forthe tetanus vaccine you received on August 6, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services (CPT 99212) provided on September 9, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not a covered
chiropractic service.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is
manual manipulation of the spine to correct a subluxation.
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that
the Plan does not have to pay for the chiropractic services (CPT 99212) provided on September
9, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveEstradiol TDS 0.0375 mg/day.You asked the Plan to pre-approvethis medication. You say that you are requesting reconsideration of the Plan's denial.The Plan denied your request. The Plan says the member has a medical (MA) only policy with "the plan", not a Prescription Drug Plan (PDP). Therefore, drug coverage is limited to Medicare Part B covered drugs.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-approveEstradiol TDS 0.0375 mg/day.Benefits for this medicationmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerningany benefits and appeal rights.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve endoscopic decompression of the spinal cord.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 services are not medically necessary.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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has mild central spinal stenosis. The requested procedure is considered experimental in nature. More research is needed to show its safety and efficacy. The services are not the standard of care and are not reasonable or 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 these services have not been met.Therefore, we decided that the Plan does not have to pre-approveendoscopic decompression of the spinal cord.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for Proton Beam Therapy services provided by "the doctor" on July 8, 2019.You asked the Plan to pay forProton Beam Therapy. You say that according to Medicare guidelines, the Plan should pay the remaining amount not paid by Original Medicare.The Plan denied your request. The Plan says the denial of payment for these services is correct, because Original Medicare is responsible for payment of these costs associated with a clinical trial so claims should be submitted to Original Medicare for payment.The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in Original Medicare and the plan cost-sharing for the same services. In this case, you asked the Plan to pay for Proton Beam Therapy as part of a clinical trial. The Plan does not cover routine costs associated with qualifying clinical trials.Therefore, we decided that the Plan does not have to pay for Proton Beam Therapy services provided by "the doctor" on July 8, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea duplex lower extremity arterial study, duplex lower extremity vein study, and ultrasound study.You asked the Plan to pre-approvethese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are not medically necessary.The Plan must follow Medicare rules. Medicare rules say that extremity scans are covered when specific criteria are met.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 you have complaints of varicose veins and leg pain. There is no documentation of an evaluation by the vascular surgery team with a rationale for why the requested studies are being ordered. There is no supporting documentation in the medical records provided that these studies are being requested or ordered. In the absence of medical record documentation of a plan to obtain the studies, the services are not reasonable or 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 these services have not been met.Therefore, we decided that the Plan does not have to pre-approvea duplex lower extremityarterial study, duplex lower extremity vein study, and ultrasound study.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forthe retrobulbar injection services coded 67500 provided on August 20, 2019.You asked the Plan to pay fortheretrobulbar injection. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services rendered are not separately payable.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, we have confirmed that code 67500 for the retrobulbar injection has a bundledrelationship with code 00140 (anesthesia for procedures on eye) and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay forthe retrobulbar injection services coded 67500 provided on August 20, 2019
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveadmission to an inpatient rehabilitation facility (IRF) for the enrollee.You asked the Planto pre-approveIRF care. You say that this is medically necessary.The Plandenied your request. The Plansaysthere is no demonstrated benefit to inpatient versus outpatient rehabilitation after hip arthroplasty.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 complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that the enrollee required the intensity of an IRF stay with close physician or nursing supervision. The enrollee may benefit and participate in additional therapy of PT and OT but the enrollee does not require this on an intensive rehabilitation facility therapy program level 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 Plandoes not haveto pre-approveadmission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvemedical necessities bag hooks (K0108) and compact remote joystick (E2373) to be provided by "the provider".You asked the Plan to pre-approvethe power wheelchair accessories. You say that please reconsider the documentation provided for the wheelchair and accessories that are medically necessary to meet the enrollee's current needs.The Plan denied your request. The Plan says the medical necessities bag hooks do not serve a medical purpose and is a convenienceitem. The compact remote joystick exceeds the enrollee's need and is not reasonable and necessary. The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  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 power wheelchair accessories. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found based on available records, the criteria indicates this joystick requires 340 grams of force to activate and the therapy notes indicate she cannot activate at this forceWe looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the power wheelchair accessories have not been met.Therefore, we decided that the Plan does not have to pre-approvemedical necessities bag hooks (K0108) and compact remote joystick (E2373) to be provided by "the provider".
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe glucose monitor, test strips, lancets, control solution, and lancet device provided by "the provider" from July 31, 2019 to October 19, 2019.You asked the Plan to pay forthe glucose monitor (E2100), test strips (A4253), lancets (A4259), control solution (A4256), and lancet device (A4258). You say that the Plan should pay this claim.The Plan denied your request. The Plan says the Delivery Ticket did not include the carriers tracking number and the Proof of Delivery did not include details to corroborate the Delivery Ticket.The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the proof of delivery documentation for the items at issuein this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. The Delivery Ticket does not have the tracking number on it and the Proof of Delivery does not have a description of the items delivered.Therefore, we decided that the Plan does not have to pay forthe glucose monitor, test strips, lancets, control solution, and lancet device provided by "the provider" from July 31, 2019 to October 19, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approvehome health skilled nursing.You asked the Plan to pre-approvethese services. You say that you need more care.The Plan denied your request. The Plan says the services are not medically necessary.The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.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 submitted records show that you currently live alone and are able to move about independently. You are able to go to outpatient doctor's appointments. The records do not show that you are homebound. Based on the submitted records, you do not require continued home health skilled nursing. The services are not required to effectively provide treatment, care, and/or services which are medically necessary for you and the records do not support that you are homebound.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-approvehome health skilled nursing.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve replacement of right leg prosthesis to be provided.You asked the Plan to pre-approve the prosthesis. You say that you need a new prosthesis that will work properly and allow you to ambulate without the risk of falling.The Plan denied your request. The Plan says the current prosthesis is less than 6 months old, still under warranty and can be repaired. The enrollee does not meet replacement criteria.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 prosthesis. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the records do not support replacement of prosthesis. Not enough documentation exists to show that the current prosthesis cannot be repaired.
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 prosthesis have not been met.Therefore, we decided that the Plan does not have to pre-approvereplacement of right leg prosthesis to be provided.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the massage therapy you received from July 19, 2019, to September 24, 2019.You asked the Plan to pay for the massage therapy. The Plan denied your request. The Plan says this is not a covered service.The Plan must follow Medicare rules. Medicare does not cover massage therapy services.Therefore, we decided that the Plan does not have to pay forthe massage therapy you received from July 19, 2019, to September 24, 2019
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveOpdivo/Nivolumab for the enrollee.You asked the Planto pre-approvethe drug. You say that this is medically necessary.The Plandenied your request. The Plansaysmedical studies haven't proven that this drug is helpful for treatment of the enrollee's health problem.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 based on the submitted documentation, regimen is a part of clinical trial DART S1609 trial (Nivolumab and Ipilimumab inTreating Patients with Rare Tumors) and current cohort is temporarily on hold. The review has determined that the documentation does not support that the Opdivo is medically reasonable and necessary for the enrollee. The documentation does not support that the Opdivo is safe and effective for the enrollee at this time.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the drug have not been met.Therefore, we decided that the Plandoes not haveto pre-approveOpdivo/Nivolumab for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says alternate settings can be requested, such as a skilled nursing facility, outpatient setting, or home health 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 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 complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that the enrollee requires the intensity of an IRF stay with close physician or nursing supervision. The enrollee may benefit and participate in additional therapy of PT and OT but the enrollee does not require this on an intensive rehabilitation facility therapy program level 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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hydrocodone-Acetaminophen for the enrollee.You asked the Plan to pre-approve this drug. You say that the patient's chronic condition requires daily around the clock opioid treatment.The Plan denied your request. The Plan says that drug coverage is limited to Medicare Part B covered drugs.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-approveHydrocodone-Acetaminophen 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea Polar Care Unit for the enrollee.You asked the Plan to pre-approvea Polar Care Unit. The Plan denied your request. The Plan says that this is not covered by Medicare.The Plan must follow Medicare rules. Medicare rules say that a fluid circulating cold pad with pump will be denied as not reasonable and necessary.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a Polar Care Unit have not been met.Therefore, we decided that the Plan does not have to pre-approvea Polar Care Unit for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Belbuca.
You asked the Plan to pre-approve Belbuca. You say that Belbuca is the best option for the enrollee. The Plan
denied your request. The Plan says the enrollee's plan does not cover outpatient prescription drugs.
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 Belbuca.
Benefits for Belbuca may be available under Medicare Part D. Contact the Plan that administers Part D benefits
for further information concerning any benefits and appeal rights.