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

We decided that the Plan does not have to pre-approve a skilled nursing facility admission.

You asked the Plan to pre-approve a skilled nursing facility admission. You say that your doctors suggested that you have physical therapy. The Plan denied your request. The Plan says the enrollee's needs are non-skilled in nature.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a skilled nursing facility admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the member did not have any parental medication, complex wound care or nutrition given via a feeding tube. The member was medically stable without any acute exacerbations of chronic medical problems. Physical function was at or near baseline and the member could have received further services at a lower level of care. Admission to a SNF for inpatient skilled care was 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 a skilled nursing facility admission have not been met. Therefore, we decided that the Plan does not have to pre-approve a skilled nursing facility admission.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve a sacroiliac (SI) joint injection.
You asked the Plan to pre-approve the injection. The Plan denied your request. The Plan says that this is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically 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 injection. Our reviewer says that the requested injection considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee is a 79-year-old woman with chronic low back pain and SI joint pain. She has had several prior SI joint injections over the past 5 years with excellent pain relief. As the enrollee has had excellent results from prior SI joint injections, the request is medically reasonable and 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 the injection have been met. Therefore, we decided that the Plan has to pre-approve a sacroiliac (SI) joint injection.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Eylea.
You asked the Plan to pre-approve Eylea. You say that the enrollee has been receiving Lucentis and has had a
poor response. The Plan denied your request. The Plan says Eylea is not medically necessary.
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 Eylea. Our reviewer says that Eylea is
not medically reasonable and necessary for the enrollee. Our physician reviewer found the Plan requires a trial
of drug Avastin before they will approve the requested drug. Our reviewer found that the enrollee has not tried
and failed the required drug. Our physician reviewer also found that there is no documentation provided
indicating that the Plan's required drug 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 Eylea have not been met. Therefore, we decided that the Plan does not have to
pre-approve Eylea.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power scooter (K0806).
You asked the Plan to pre-approve the power scooter. You say that a new power scooter is medically necessary due to an upcoming surgical procedure. The Plan denied your request. The Plan says the record shows you have an existing power scooter that is less than 5 years old and can be repaired.
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. The file shows that you have an existing group 2 power scooter. The requested new power scooter serves the same purpose as this existing power scooter that is eligible for coverage for needed repairs. Therefore, we decided that the Plan does not have to pre-approve a power scooter (K0806).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve custom foot orthotics.
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 covered.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve custom foot orthotics.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to provide Mircera.
You asked the Plan to provide Injection, epoetin beta, 1 microgram, (for esrd on dialysis) (J0887). You say that the enrollee needs this injection. The Plan denied your request. The Plan says the injection would be billed to Medicare Part B bundled payment by the dialysis facility.
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 Injection, epoetin beta, 1 microgram, (for esrd on dialysis) (J0887) has a bundled relationship with dialysis and cannot be separately paid. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. The Plan is not denying the drug for medical necessity but denying for being a bundled payment. Therefore, we decided that the Plan does not have to provide Mircera.
Benefits for Injection, epoetin beta, 1 microgram, (for esrd on dialysis) (J0887) 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: 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 the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has 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 there is no evidence that the enrollee requires services that are not currently available. As LTACHs and acute care hospitals (ACHs) are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long-term care (LTC) needs.

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: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Orthovisc.
You asked the Plan to pre-approve Orthovisc. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage 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 Orthovisc. Our reviewer says that the medication is not medically necessary. Our physician reviewer found the Plan requires a trial of drug Durolane before they will approve the requested drug. In this case, you have 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 you. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Orthovisc have not been met. Therefore, we decided that the Plan does not have to pre-approve Orthovisc.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Repatha Sureclick.
You asked the Plan to pre-approve Repatha. You say that this is the only medication that works for the enrollee's condition. The Plan denied your request. The Plan says the enrollee's medical 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 Repatha Sureclick.
Benefits for Repatha 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 pre-approve a walk-in bathtub.
You asked the Plan to pre-approve the bathtub. You say that due to COVID you cannot use the pool at the gym. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a walk-in bathtub.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Foundation One Liquid testing.

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 next generation sequencing is 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 the enrollee has a history of invasive high-grade papillary bladder carcinoma with neoadjuvant chemotherapy, followed by surgery. He now has recurrent bladder cancer on the pelvic side wall. Next generation sequencing was ordered to evaluate for any actionable gene mutations. Foundation One CDX solid tumor testing that was approved by the plan. There is no documentation that the solid tumor testing could not be completed. At this time, the documentation supports that the enrollee has been previously tested with the same test using NGS for the same genetic content.

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 Foundation One Liquid testing.
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 these services are medically necessary. The Plan denied your request. The Plan says that your ongoing skilled therapy and nursing needs can be provided 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. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for weakness and falls, when you were transferred to skilled nursing where you are receiving physical therapy services. Your medical problems are stable. There are no complex nursing or rehabilitation needs. You do 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 you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your condition does not meet Medicare criteria for IRF 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for cardiovascular risk assessment testing provided on September 3, 2020.
You asked the Plan to pay for the cardiovascular risk assessment testing. You say that you would like reconsideration because this testing was medically necessary. The Plan denied your request. The Plan says Medicare only covers the basic lipid panel.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the cardiovascular risk assessment testing. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found Medicare denies coverage for all cardiovascular risk assessment testing/panels, except the basic lipid panel, for symptomatic patients with suspected or documented cardiovascular disease. There was no specific clinical rationale for the obtained lab studies. 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 cardiovascular risk assessment testing have not been met. Therefore, we decided that the Plan does not have to pay for cardiovascular risk assessment testing provided on September 3, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the CardioMEMS procedure.
You asked the Plan to pre-approve CardioMEMS. You say that this is medically necessary for the enrollee's specific clinical need. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because CardioMEMS is 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 CardioMEMS. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the efficacy of the CardioMEMS device remains uncertain at this time. Further clinical study is needed to determine the safety and efficacy of this device. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CardioMEMS have not been met. Therefore, we decided that the Plan does not have to pre-approve the CardioMEMS procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core build up (D2950) for tooth # 15.
You asked the Plan to pre-approve the dental service. You say that the core build up is medically necessary. The Plan denied your request. The Plan says core build up is not listed as a covered service.
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 build up (D2950) for tooth # 15.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the Ambulance service, basic life support, non-emergency transport (A0428, A0425) provided September 17, 2020, to November 12, 2020.
You asked the Plan to waive the copayment for the ambulance service. You say that the copayments do not appear to be correct. The Plan denied your request. The Plan says the copayments were 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $270 copayment per date of service regardless of the number of trips for non-emergency ground ambulance. The enrollee has been asked to pay a total of $4,663 for the 25 ambulance service trips. These services fall within the Ambulance services benefit category. The cost-sharing applied to the enrollee is less than the required copayment of $270 per trip. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the Ambulance service, basic life support, non-emergency transport (A0428, A0425) provided September 17, 2020, to November 12, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve the SNF admission. You say that the enrollee was at a crucial point in his speech therapy when he aspirated. He was supposed to have 30 days of rehabilitation which was interrupted. He has not gotten all the services he was due. The Plan denied your request. The Plan says there are no daily skilled needs for which SNF placement is required.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee was being treated in the SNF but required readmission to the hospital on 3/6/2021 due to aspiration. The most recent therapy documentation indicates the member requires maximal assistance with bed mobility and is dependent for transfers and mobility/locomotion. He continues to require assistance for all self-care tasks. His baseline level of cognition appears to limit his ability to cooperate with skilled therapy. The member did not require any skilled nursing or rehab services on a daily basis at an inpatient level of care. He was not expected to make measurable gains within a reasonable and predictable period of time or require skilled therapy to prevent deterioration with mobility or daily living activities. The member did not require skilled therapy to establish a safe and effective maintenance program. As a practical matter, the member did not require any skilled services on an inpatient basis, at a SNF level of care at the time of discharge from the hospital. He was medically stable without any acute exacerbations of chronic medical problems. His physical function was at or near his baseline and he could receive further services 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 the SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).