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

We decided that the Plan does not have to pre-approve Tildrakizumab (Ilumya).

You asked the Plan to pre-approve Ilumya. You say that you would like Ilumya to be approved for the enrollee. The Plan denied your request. The Plan says this request does not meet the Plan's Part B step therapy criteria for Ilumya.

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 Ilumya is not medically reasonable and necessary for the enrollee. Our physician reviewer found based on the medical records provided, the enrollee has not tried and failed the required drugs, Inflectra or Remicade. Our reviewer also found that there is no indication that the Plan's required drugs would likely be less effective and/or likely have adverse effects for the enrollee. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Ilumya have not been met. Therefore, we decided that the Plan does not have to pre-approve Tildrakizumab (Ilumya).
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 would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested admission is not medically necessary.

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 you were admitted for anorexia, weakness, and end stage renal disease. The documentation does not support that you require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not support that you require an intensive rehabilitation therapy program. Your care needs can be met at a lower 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex Superion spacer.

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 multiple degrees of spinal stenosis not at FDA-indicated levels of moderate spinal stenosis. The requested Superion spacer is not the standard of care over the gold standard of lumbar laminectomy. The services are considered experimental in nature and 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex Superion spacer.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a neurostimulator.

You asked the Plan to pre-approve percutaneous implantation of neurostimulator electrode array; sacral nerve (Transforaminal placement) including image guidance, if performed (64561). You say that the neurostimulator is medically necessary based on urge incontinence. The Plan denied your request. The Plan says the enrollee does not meet medical necessity 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 percutaneous implantation of neurostimulator electrode array; sacral nerve (Transforaminal placement) including image guidance, if performed (64561). Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee does not meet medical necessity criteria. Specifically, the medical records indicate that this patient has a spinal cord injury which excludes coverage for neurostimulator implantation.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of percutaneous implantation of neurostimulator electrode array; sacral nerve (Transforaminal placement) including image guidance, if performed (64561) have not been met. Therefore, we decided that the Plan does not have to pre-approve a neurostimulator.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the behavioral assessment provided by an out of network (OON) provider.

You asked the Plan to pay for the behavioral assessment. You say that the services were medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan 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 behavioral assessment provided by an out of network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for radiation therapy provided from September 30, 2020, through November 11, 2020.

You asked the Plan to waive the copayments for radiation therapy. You say that you weren't informed there would be a copayment charged for each visit. You say that you would have elected the Mohs surgery instead of therapy. The Plan denied your request. The Plan says the copayments applied correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 copayment for each Medicare-covered radiation therapy service. 

You have been asked to pay a $50 copayment for each radiation therapy treatment. The total amount you owe is $1,100 ($50/treatment x 22 treatments = $1,100). Radiation therapy falls within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" benefit category. The Evidence of Coverage states the copayment for radiation therapy applies to each service. 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 copayments for radiation therapy provided from September 30, 2020, through November 11, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an upper endoscopy (CPT code 43235).

You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your request. The Plan says an upper endoscopy is not medically necessary at this time because the documentation received fails to indicate the member has had a negative colonoscopy.

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 service. Our physician reviewer found the LCD indicates that an upper endoscopy for the presence of gastrointestinal bleeding is considered medically necessary for presumed chronic blood loss and for iron deficiency when a colonoscopy is negative. In this case, you have presumed chronic blood loss from a gastrointestinal source. You have not had a lower endoscopy. The elements of the LCD are not satisfied. The requested service is not recommended. 

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 service have not been met. Therefore, we decided that the Plan does not have to pre-approve an upper endoscopy (CPT code 43235).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652).

You asked the Plan to pre-approve a pneumatic compression device. You say that this item is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the coverage criteria for the pneumatic compression device has not been met.

The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required. 

We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (E0652).
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 needs rehab. The Plan denied your request. The Plan says the services are not medically necessary.

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 medically necessary. Our physician reviewer found the IRF screening dated April 5, 2021 states that the enrollee needs maximal assistance with activities of daily living and mobility. She does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to be able to perform 15 hours per week of rehabilitative services and regular physician evaluation. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided by an out of network (OON) provider.

You asked the Plan to pay for the office visit. You say that the services were medically necessary. 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 pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 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 office visit provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the first 15 minutes of intravenous moderate (conscious) sedation/analgesia and each subsequent 15 minute increment of intravenous moderate (conscious) sedation/analgesia.

You asked the Plan to pre-approve the intravenous moderate (conscious) sedation/analgesia services. You say that you would like these services approved for coverage. The Plan denied your request. The Plan says your plan does not cover these procedures.

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 the first 15 minutes of intravenous moderate (conscious) sedation/analgesia and each subsequent 15 minute increment of intravenous moderate (conscious) sedation/analgesia.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ECG provided on October 5, 2020.

You asked the Plan to waive the copayment for an ECG. You say that you disagree with the additional charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $10 copayment for diagnostic procedures and tests. 

You have been asked to pay a $10 copayment for an ECG. An ECG falls within the outpatient diagnostic tests and therapeutic services and supplies 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 an ECG provided on October 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the interrogation device evaluation provided by an out-of-network provider on April 21, 2020.

You asked the Plan to pay for the interrogation device evaluation. You say that authorization is not required for an in-network provider. You say that you expect proper reimbursement for your service. The Plan denied your request. The Plan says prior authorization was required but not obtained.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan 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 interrogation device evaluation provided by an out-of-network provider on April 21, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitor.

You asked the Plan to pre-approve a Dexcom G6 continuous glucose monitor. You say that this device is
medically necessary. The Plan denied your request. The Plan says there is no reason the Plan's preferred brand
cannot be used.

The Plan follows Medicare rules. Medicare rules say that the Plan may specify certain brands and
manufacturers as preferred.

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 a Dexcom G6 continuous glucose
monitor. Our reviewer says that it is not medically necessary for the enrollee to use the Dexcom G6 continuous
glucose monitor over the Plan's preferred brand Freestyle Libre 2 continuous glucose monitor. Our physician
reviewer found although the enrollee prefers the low blood glucose alert feature of the Dexcom G6, the
Freestyle Libre would also be able to perform this service. There is insufficient data that the enrollee must use
the Dexcom G6 over the Freestyle Libre. If there is a reason why this patient cannot use the reader, this
information should be provided and the case re-reviewed.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of a Dexcom G6 continuous glucose monitor have not been met. Therefore, we
decided that the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the group 2 power operated vehicle (K0808).

You asked the Plan to pre-approve the group 2 power operated vehicle. You say that this request is medically necessary. The Plan denied your request. The Plan says this is not a covered service because it has added capabilities that are not needed for use in the home.

The Plan must follow Medicare rules. Medicare rules say that group 2 power operated vehicles have added capabilities not needed for use in the home and 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 the group 2 power operated vehicle have not been met. Therefore, we decided that the Plan does not have to pre-approve the group 2 power operated vehicle (K0808).
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 need IRF services to return your prior level of function. The Plan denied your request. The Plan says you can stay in the hospital to finish treatment.

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 patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical 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 patient 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 Cerovel.

You asked the Plan to pre-approve Cerovel. You say that you have used this medication in the past and would
like for it to be approved. The Plan denied your request. The Plan says your Medicare Advantage (MA) 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 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 Cerovel.

Benefits for Cerovel 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis and the addition to lower extremity orthosis.

You asked the Plan to pay for the knee orthosis and the addition to lower extremity orthosis. You say that you
would like the plan to reconsider their denial. The Plan denied your request. The Plan says the documentation
is missing required information.

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 does not contain a valid proof of delivery for the supplies provided in this case. Review of the file
shows that the documentation does include a proof of delivery but does not indicate the specific supplies
delivered for the billed date of service. The record shows that the Plan made several attempts to obtain the
necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the
knee orthosis and the addition to lower extremity orthosis.