Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a drug eluting implant (0356T).
You asked the Plan to pre-approve the implant. The Plan denied your request. The Plan says this is not a covered service.
The Plan must follow Medicare rules. Medicare rules say that Local Coverage Article A56195 provides a list of Category III CPT codes that are considered not medically necessary. We looked at the file and Medicare rules. Per A56195, Category III CPT code 0356T is considered not medically necessary. Based on this information, we decided that Medicare rules for coverage of the requested implant have not been met. Therefore, we decided that the Plan does not have to pre-approve a drug eluting implant (0356T).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission.
You asked the Plan to pre-approve SNF admission. The Plan denied your request. The Plan says SNF admission is not medically necessary.
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 admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that this enrollee does not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment in a SNF. The enrollee does not have a tracheostomy tube, complex wound care or other SNF level skilled nursing need. This enrollee's high functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist required to safely and effectively provide medically necessary and reasonable treatment. The enrollee does not require these skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis". As a practical matter, this enrollee does not require the necessary services on an inpatient basis, in a skilled nursing facility setting. 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 admission have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for automatic external defibrillator, with integrated electrocardiogram analysis, garment type (CPT Code K0606) provided from May 29, 2019 through July 29, 2019.
You asked the Plan to waive the coinsurance for the DME. You say that you are appealing your cost-share responsibility for the services you received. The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you rented DME from May 29, 2019 through July 29, 2019. You are asked to pay 20% coinsurance for the DME. 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 coinsurance for automatic external defibrillator, with integrated electrocardiogram analysis, garment type (CPT Code K0606) provided from May 29, 2019 through July 29, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve expandable controller (E2377) expandable controller harness (E2313) electronic connector to 2 power options (E2311).
You asked the Plan to pre-approve the power wheelchair accessories. You say that please see the letter explaining the medical necessity for these components and process for reconsideration. The Plan denied your request. The Plan says the requested upgraded electronics 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 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 the documentation does not reveal that the enrollee requires a proportional input device, an attendant control, other electronic devices such as augmentative speech device, a separate display, a non-proportional input device such as sip and puff, or the need to control 3 or more power seating actuators through the drive control. The enrollee's strength in the right upper extremity is sufficient to control the power options with their separate switches already included with the approval of these power options 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 power wheelchair accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve expandable controller (E2377) expandable controller harness (E2313) electronic connector to 2 power options (E2311).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Supartz FX.
You asked the Plan to pre-approve Supartz FX. The Plan denied your request. The Plan says the enrollee has not met the step therapy requirements.
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 Supartz FX. Our reviewer says that Supartz FX is not medically reasonable and necessary. Our physician reviewer found that the enrollee has not had a trial of Monovisc and Orthovisc. The documentation does not support that Monovisc and Orthovisc would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Supartz FX have not been met. Therefore, we decided that the Plan does not have to pre-approve Supartz FX.
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 care to return to your previous level of function. The Plan denied your request. The Plan says you can be treated 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 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 records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a skilled nursing facility (SNF) level of care. Ongoing pain medication and other medication management, wound care, monitoring of neurological status, and daily therapy can be provided at a SNF. In regards to therapy, a less intensive, longer duration of therapy will allow for measurable gains to be attained within a predicted period. 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eyewear purchased from an out-of-network provider on September 25, 2019.
You asked the Plan to pay for the eyewear. You say that you are requesting reimbursement of services rendered. The Plan denied your request. The Plan says you must use a plan provider.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the eyewear have not been met. The health plan contract says that enrollees have a $100 eye wear allowance every two years. You must use a plan provider for this benefit. The provider selected is not a Plan provider. Therefore, we decided that the Plan does not have to pay for eyewear purchased from an out-of-network provider on September 25, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve implantable loop recorder.
You asked the Plan to pre-approve the implantable loop recorder. You say that the medical records provided will show proof of medical necessity. The Plan denied your request. The Plan says there is no documentation to support the request for medical necessity of the loop recorder.
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 implantable loop recorder. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the loop records are considered appropriate when patients present with syncope that is thought to be cardiac in origin but has not been identified by either Holter monitor or extended external event monitors. The records provided to not support the enrollee has undergone the needed evaluations. Therefore the records do not support the medical necessity for an implantable loop recorder 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 implantable loop recorder have not been met. Therefore, we decided that the Plan does not have to pre-approve implantable loop recorder.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Eliquis tab 5mg for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says the requested medication is 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 Eliquis tab 5mg for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a backup battery for CPAP machine.
You asked the Plan to pre-approve a backup battery. The Plan denied your request. The Plan says this is not covered by Medicare.
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 backup battery for CPAP machine.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an epidural steroid injection.
You asked the Plan to pre-approve an epidural steroid injection. The Plan denied your request. The Plan says this 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 an epidural steroid injection. Our reviewer says that the requested epidural steroid injection is not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee has chronic low back pain, with radiation down their leg. The enrollee had a prior epidural steroid injection which gave them one month of 40% pain relief. Since the enrollee did not achieve 50% pain relief from the prior injection, the request is considered 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 an epidural steroid injection have not been met. Therefore, we decided that the Plan does not have to pre-approve an epidural steroid injection.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ensure nutritional supplements.
You asked the Plan to pre-approve the requested items. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation. The items you asked the Plan to pre-approve are nutritional supplements. Nutritional supplementation is not covered under Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Ensure nutritional supplements.
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 feel that you require this level of care. The Plan denied your request. The Plan says you are medically stable and do not require intensive therapy for your condition.
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 enrollee was admitted for a right elbow injection which failed outpatient treatment with antibiotics. The enrollee underwent a drainage procedure on 1/25/2020. The complexity of the patient'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 patient's medical status requires the intensity of an IRF stay with close physician or nursing supervision. The patient may benefit and participate in additional therapy of PT and OT but the patient 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Humira injector pens.
You asked the Plan to pre-approve self-administered drugs. You say that the enrollee has tried and failed
several other medications, and this is the only one that has kept him stable. 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 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 Humira injector pens.
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient admission for alcohol detoxification.
You asked the Plan to pre-approve inpatient admission for alcohol detoxification. The Plan denied your request. The Plan says this is not medically necessary.
The Plan follows Medicare rules. Medicare rules say that inpatient admission for alcohol detoxification is covered when the above 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 inpatient admission for alcohol detoxification. Our reviewer says that the requested inpatient hospital care is not medically reasonable and necessary. Our physician reviewer found that the enrollee does not require inpatient mental health treatment beyond the dates in question as noted above as they are not a danger to themselves or others and does not have any auditory or visual hallucinations or behavioral issues. It does not appear that active treatment is taking place beyond the date in question. This enrollee does not meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in question of January 31, 2020 forward, and can be treated in a less restrictive setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient admission for alcohol detoxification have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient admission for alcohol detoxification.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) admission.
You asked the Plan to pre-approve the SNF services. You say that the enrollee has not had any care, cannot walk and lives on their own. They need to have physical therapy because they broke their left femur and cannot get any food or go to the bathroom. The Plan denied your request. The Plan says the request does not meet medical necessity criteria.
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 the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. The enrollee does have skilled therapy service needs but does not require skilled therapy on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) admission.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Temsirolimus.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says off-label use of a drug is medically accepted when there is evidence in one or more of the compendia in the medical literature.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found the requested use of this drug is not FDA-approved for the enrollee's diagnosis. The use of this drug is not supported by any of the major drug compendia, or by clinical research. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Temsirolimus.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve epinephrine auto-injectors.
You asked the Plan to pre-approve the epinephrine injectors. You say that this is medically necessary. The Plan denied your request. The Plan says this self-injected medication is not covered by Medicare Part B.
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 epinephrine auto-injectors.
Benefits for the epinephrine injectors may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.