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

We decided that the Plan has to pre-approve Orthovisc.

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 that the step therapy requirement is not met.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. 

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan states that the services are not medically necessary because you have not tried and failed their required drugs, Synvisc/Synvisc-One or Euflexxa; however, no medical records were submitted with the case file. Without medical records, your prior treatment(s) are not documented and a determination based on medical necessity cannot be supported. Therefore, we decided that the Plan has to pre-approve Orthovisc.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for ultrasounds (76770, 76856) provided on
October 24, 2020.
You asked the Plan to waive the deductible for ultrasounds. You say that you did not know this would not be
covered. The Plan denied your request. The Plan says these services are covered, but the deductible applied
correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your
contract with the Plan says that there is a $500 deductible for inpatient hospital care, outpatient diagnostic
services, ambulatory surgical services, and outpatient hospital services.
The services you asked the Plan to waive the deductible for are outpatient diagnostic services. The Plan has
followed Medicare rules by clearly disclosing in the contract that there is a $500 deductible for inpatient
hospital care, outpatient diagnostic services, ambulatory surgical services, and outpatient hospital services. This
cost sharing is a contractual obligation that had not been met at the time ultrasounds were received on October
24, 2020. Therefore, we decided that the Plan does not have to waive the deductible for ultrasounds (76770,
76856) provided on October 24, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve spinal fusion/laminectomy surgery.
You asked the Plan to pre-approve spine surgery. You say that you cannot do any type of therapy due to your medical condition. The Plan denied your request. The Plan says this surgery is not medically necessary for you.
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 spine surgery. 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 show any reason why you cannot have physical therapy. Physical therapy for neck pain and symptoms of neck degeneration should be attempted. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of spine surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve spinal fusion/laminectomy surgery.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says this is experimental and investigational.
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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the device is experimental. More research is needed to show safety efficacy of the 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 the device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an additional ten (10) PT visits.
You asked the Plan to pre-approve the additional ten (10) PT visits. The Plan denied your request. The Plan says additional PT visits are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the additional ten (10) PT visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found that the enrollee has had previous therapy and should be independent with a home exercise program. The additional physical therapy sessions are considered excessive and not an appropriate duration and frequency for the enrollee's medical condition. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the additional ten (10) PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve an additional ten (10) PT visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a stair glide.
You asked the Plan to pre-approve a stair glide. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says coverage cannot be made for this item.
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they are not primarily medical in nature. While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a stair glide.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc (J7325).
You asked the Plan to pre-approve Synvisc. You say that this drug is necessary. The Plan denied your request.
The Plan says the enrollee has not tried and failed the preferred step therapy drugs, Monovisc and Orthovisc.
The Plan also says that there is no indication our preferred agents would likely be less effective, and/or cause
adverse effects for the enrollee.
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 Synvisc. Our reviewer says that
Synvisc is not medically necessary. Our physician reviewer found the Plan requires a trial of drug Orthovisc
and Monovisc before they will approve the requested drug. The reviewer found that the enrollee has not tried
and failed the required drugs. The reviewer found there is no documentation provided indicating that the Plan's
required drugs likely be less effective and/or likely have adverse effects for the enrollee. Therefore, the
reviewer found that the requested drug is not medically reasonable or 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 Synvisc have not been met. Therefore, we decided that the Plan does not have
to pre-approve Synvisc (J7325).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to reduce the cost share for a Prolia injection.

You asked the Plan to reduce the cost share for the injection. The Plan denied your request. The Plan says a tier
exception cannot be granted for a Part B medication.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
co-payments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees
must pay a $15 copay for administration of drugs at a primary care physician's office, and a $25 copay for
administration of drugs at a specialist office.

The services fall within the Medicare Part B prescription drugs. benefit category. This means that the cost share
is 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 reduce
the cost share for a Prolia injection.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve durable medical equipment to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve durable medical equipment. You say that you need a CPAP machine. The Plan denied your request. The Plan says there are in-network providers available for these services.

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 durable medical equipment to be provided by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Supartz FX injection for the enrollee.
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your
request. The Plan says step therapy guidelines were not followed.
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 the injection. Our reviewer says that the
requested services are not medically reasonable or necessary. Our physician reviewer found based on the
medical records provided, the enrollee has not tried and failed Orthovisc or Monovisc. There is no indication
that these drugs would likely be less effective and/or likely have adverse effects.
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 not been met. Therefore, we decided that the Plan does not
have to pre-approve a Supartz FX injection for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bedside commode (E0167).
You asked the Plan to pre-approve a bedside commode. You say that the requested item is medically necessary. The Plan denied your request. The Plan says this item does not meet the Medicare criteria for approval.
The Plan must follow Medicare rules. Medicare rules say that a bedside commode is covered when the beneficiary is confined to a single room, or the beneficiary is confined to one level of the home environment and there is no toilet on that level, or the beneficiary is confined to the home and there are no toilet facilities in the home We looked at the file and Medicare rules. The case record indicates that none of the criteria have been met for the enrollee. Based on this information, we decided that Medicare rules for coverage of a bedside commode have not been met. Therefore, we decided that the Plan does not have to pre-approve a bedside commode (E0167).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the therapeutic prophylactic injection provided on December 15, 2020.
You asked the Plan to waive the copayment for the therapeutic prophylactic injection. You say that it was your understanding that your financial responsibility would be $36. You say that this was a 15-minute procedure and you should not have to pay this much. The Plan denied your request. The Plan says the copayment 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 $225 copayment per visit for outpatient surgery or procedure. You have been asked to pay $186.61, which is less than the standard $225 copayment for the therapeutic prophylactic injection. The therapeutic prophylactic injection falls within the "Outpatient hospital services" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the therapeutic prophylactic injection provided on December 15, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a negative pressure wound therapy (NPWT) electrical pump for the enrollee.
You asked the Plan to pre-approve a NPWT pump. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says your request for continued wound VAC NPWT pump therapy on the enrollee's sacral and ischium wounds is not medically necessary because records show the enrollee has been using the wound VAC NPWT device for greater than 4 months.
The Plan must follow Medicare rules. Medicare rules say that a NPWT pump and supplies will be denied as not reasonable and necessary when 4 months have elapsed using a NPWT pump in the treatment of the most recent wound. We looked at the file and Medicare rules. The file indicates the enrollee has been using the NPWT pump for more than four months. Based on this information, we decided that Medicare rules for coverage of a NPWT pump have not been met. Therefore, we decided that the Plan does not have to pre-approve a negative pressure wound therapy (NPWT) electrical pump for the enrollee.
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to waive the copayment for the office visit provided on November 20, 2020. We decided that the Plan does not have to waive the copayment for the urgent care visit provided on November 12, 2020.
You asked the Plan to waive the copayment for the urgent care visit and office visit. You say that you do not agree with the $65 charge for both claims. The Plan says that the copayments applied correctly.
We decided that the Plan has to waive the copayment for the office visit provided on November 20, 2020.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan did not submit documentation supporting the office visit was provided at an urgent care facility on November 20, 2020. This means that we cannot determine the copayment you are being asked to pay is correct or justified by the Plan contract. Therefore, we decided that the Plan has to waive the copayment for the office visit provided on November 20, 2020.
We also decided that the Plan does not have to waive the copayment for the urgent care visit provided on November 12, 2020.
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 $65 copayment per visit for Medicare-covered urgently needed services. Therefore, we decided that the Plan does not have to waive the copayment for the urgent care visit provided on November 12, 2020.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve the CardioMEMS system for the enrollee.

You asked the Plan to pre-approve the system. You say that this is medically necessary. The Plan denied your request. The Plan says that research studies have found a lack of evidence that routine use of this study would improve the outcome for this type of condition.

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 system. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has ischemic heart failure and is on maximally tolerated CHF medications and device therapy (BiV/ICD) but with recent hospitalization for decompensated CHF and persistent NYHA Class III symptoms. Management of his heart failure with standard medical therapy and relying on symptoms and signs has not been effective in keeping him with minimal symptoms and has resulted in acute hospitalization. Guideline-directed medical therapy has been limited by hypotension in this instance as well. The use of this device in this situation can provide additional heart filling pressure data to better manage his diuretic and vasodilator regimens. Given the ongoing severe symptoms of recurrent congestive heart failure which appear to be sensitive to volume-loading conditions, the maximal medical regimen and the failure to prevent acute congestive heart failure hospitalization, the use of the CardioMEMS device is reasonable and has clinical data, expert opinion, and approved FDA indications to back up its use in selected appropriate clinical situations like this one. 

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 system have been met. Therefore, we decided that the Plan has to pre-approve the CardioMEMS system for the enrollee.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Betamethasone Dipropionate cream 0.05% for the enrollee.
You asked the Plan to pre-approve the cream. You say that this is medically necessary. The Plan denied your request. The Plan says this medication was denied as a benefit exclusion
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 Betamethasone Dipropionate cream 0.05% for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ilumya injection.

You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says you do not want to attempt step therapy.

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 the injection. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found there is no evidence of a trial and failure of Inflectra or Renflexis. Based on the medical records provided, there is no indication that the plan's required drugs would likely be less effective and/or likely have adverse effects. 

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 not been met. Therefore, we decided that the Plan does not have to pre-approve Ilumya injection.