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

We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) services at a contracted tertiary facility.You asked the Plan to pre-approve the MRI at a contracted tertiary facility. You say that you have severe spinal disease and were born with a partial deformity. You say that you have a walker, wheelchair, cane, and foot massager to assist with your feet. You say that you have severe pain from your nerves in the spine and cannot take Advil or aspirin to reduce the pain due to a blood disease. You say that you are no longer able to get epidural injections because you have a crack in your spine which causes the doctor complications when trying to get the needle in.The Plan denied your request. The Plan says the enrollee can get medically needed care from a non-tertiary facility.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 MRI at a contracted tertiary facility. Our reviewer says that the documentation provided does not support that it is medically reasonable and necessary for the enrollee to receive the MRI at a tertiary level of care. Our physician reviewer found the plan's denial is medically justified on the basis that it is offering adequate care to meet the enrollee's medical needs through a referral to a non-tertiary facility.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 MRI at a contracted tertiary facility have not been met.Therefore, we decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) services at a contracted tertiary facility.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Mycophenolate capsules.You asked the Plan to pre-approve self-administered drugs. You say that this is an anti-rejection drug for your liver transplant, and if you miss even 1 dose of this medication you will lose your life.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 your Medicare Part D prescription drug benefits. The Plan also says that your Medicare Part D benefits may be administered by Express Scripts.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 Mycophenolate capsules.Benefits for self-administered drugs may be available under Medicare Part D.Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Enbrel Sureclick for the enrollee.You asked the Plan to pre-approve Enbrel. You say that the enrollee has done very well on Enbrel.The Plan denied your request. The Plan says the enrollee's plan does not cover outpatient prescription drugs.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pre-approve Enbrel Sureclick forthe enrollee.Benefits for Enbrel 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-approvea seat elevator and an expandable controller/harness/electrical connection
You asked the Plan to pre-approvethe services. You say that this is medically necessary.The Plan denied your request. The Plan says the seat elevator does not serve a primarily medical purpose, and it is not medically necessary to control the three approved power options through the joystick (drive interface).The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  The seat elevator at issue in this appeal does not serve a purpose that is primarily medical in nature. Thisitem is available to the general public and would be helpful even to those who are not sick or injured. Additionally, our MAXIMUS physician reviewer found that the expandable controller/harness/electrical connection is also not medically necessary as the documentation does not reveal that the patient's strength in the upper extremities is such that she must use other types of proportional input devices (e.g., mini-proportional or compact joysticks, touchpads, chin control, head control, etc.). The documentation does not indicates that she must use other non-proportional input devices (e.g., sip and puff, head array, etc.). The enrollee does not require a separate display, attendant control, or other electronic devices through an expandable controller. The enrollee does not need to operate 3 or more powered seating actuators through the drive control. The approved power options already come with their own switches and the documentation does not indicate that the patient's upper extremity function/strength is insufficient to use the individual switches.Therefore, we decided that the Plan does not have to pre-approvea seat elevator and an expandable controller/harness/electrical connection
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CT scan of the abdomen/pelvis.You asked the Plan to pre-approve the CT scan. You say that the enrollee needs this imaging to determine the cause for her symptoms.The Plan denied your request. The Plan says other diagnostic testing should be performed prior to advanced imaging.The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 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 CT scan. Our reviewer says that the requested imaging is not considered medically reasonable and necessary. Our physician reviewer found the enrollee is a female with normal liver function tests, normal chemistry, and normal blood count. The enrollee has recent symptoms of intermittent loose stool. CT scan is not medically warranted at this time in light of the uncomplicated nature of the enrollee's intermittent loose stool. There were no findings on prior CT imaging which would warrant follow-up with the same imaging. Alternate imaging should be considered prior to CT scan.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 CT scan have not been met.Therefore, we decided that the Plan does not have to pre-approve a CT scan of the abdomen/pelvis.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approveDurolane injections.
You asked the Plan to pre-approvethese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the step therapy requirement is not 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has pain related to osteoarthritis of both knees that has been confirmed with imaging. She has failed conservative treatment. She has not tried and failed the plan's required drugs of Orthovisc and Monovisc. The records do not show that these drugs would be less effective or contraindicated; therefore, Durolane is not reasonable or medically necessary.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pre-approveDurolane injections.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve methocarbomol 500mg tablets.
You asked the Plan to pre-approve the methocarbomol tablets. You say that this is a necessary medication. The Plan denied your request. The Plan says this oral drug 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 methocarbomol 500mg tablets.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea mastectomy sleeve coded as L8010.You asked the Plan to pre-approvethe mastectomy sleeve. You say that you need this compression sleeve due to your lymphedema which causes your arm to almost double in size at times.The Plan denied your request. The Plan says this is not a covered item under Medicare.The Plan must follow Medicare rules. Medicare rules say that breast prostheses are covered under the Medicare Prosthetics benefit. A mastectomy sleeve cannot be covered because it does not meet the definition of a prosthesis.Although this may be appropriate for you, it does not fall within a covered Medicare benefit category.Therefore, we decided that the Plan does not have to pre-approvea mastectomy sleeve coded as L8010.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sacroiliac joint injections.
You asked the Plan to pre-approve the injections. You say that this is medically necessary. The Plan denied your request. The Plan says the requested service is supported when it will be the only service to the same region of the spine on the same date of service
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 injections. Our reviewer says that the requested sacroiliac joint injections are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no role for a series of injections. Each intervention needs to be evaluated for effectiveness and duration of relief. Here, the diagnostic block did not provide sustained relief. Therefore, further therapeutic blocks are not indicated. The requested procedures are 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 the injections have not been met. Therefore, we decided that the Plan does not have to pre-approve sacroiliac joint injections.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health physical therapy and speech therapy services for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the remaining requested services are denied as not medically necessary.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found the enrollee has had extensive prior therapy and her functional needs do not require the professional skilled services of a therapist. The request for home health social services are additionally not medically necessary beyond what the health plan has approved. The enrollee was approved one final SW visit for discharge. There are no extenuating factors that would require additional home health social services for the treatment of the patient's injury or illness. Additionally, without the ongoing need of skilled therapy or skilled nursing the request for home health services is not medically necessary per Section 50.2.
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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve home health physical therapy and speech therapy services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.You asked the Plan to pre-approve SNF services. You say that you need more therapy to gain your strength back.The Plan denied your request. The Plan says that you have exceeded the goals that were in place upon your admission.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for continued SNF services.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met.Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pay forhome infusion therapy (HCPCS S9325 and S9328)You asked the Planto pay forthe services. You say that you have had back pain for ten years and it is getting worse.The Plandenied your request. The Plansaysthese codes are not valid for Medicare purposes.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code.We find that HCPCS codes S9325 and S9328 are not supported in the medical record. Specifically, these codes have a status indicator of I according to the Medicare Physician's Fee Schedule. This indicates that these codes are not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plandoes not haveto pay forhome infusion therapy (HCPCS S9325 and S9328).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient mental health services. You asked the Plan to pre-approve continued inpatient services. The Plan denied your request. The Plan says the enrollee is not displaying thoughts of self-harm.The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. The file shows that continued inpatient services beyond November 5, 2019 was requested for 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 continued inpatient services. Our physician reviewer found that the enrollee was not shown to be a danger to herself or others. She is noted to be cooperative and compliant with treatment while not showing any aggressive behaviors. It did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care. Active treatment was not taking place. The services were not reasonably expected to improve the enrollee's condition or for the purpose of diagnosis. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued inpatient services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued inpatient mental health services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional power wheelchair accessories(push handles, Q-Logic enhanced display kit, custom back height, adjustable back, drive control harness, power seat elevation).You asked the Plan to pre-approve the accessories. You say that this is medically necessary.The Plan denied your request. The Plan says these do not serve a medical purpose.The Plan must follow Medicare rules. Medicare rules say that for durable medical equipment to be covered, it must serve a medical purpose.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the accessories. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the request for additional power wheelchair accessories is not medically necessary. The K0108 push handles and power seat elevation do not primarily serve a medical purpose. The enhanced display kit and drive harness control are already included with the approved E2377 controller. The custom back and adjustable back pads are included in the approved back cushion.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 accessories have not been met.Therefore, we decided that the Plan does not have to pre-approve additional power wheelchair accessories (push handles, Q-Logic enhanced display kit, custom back height, adjustable back, drive control harness, power seat elevation).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approves tab phlebectomy.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 stab phlebectomy 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 there is no documentation that the enrollee's tributary veins are six millimeters or greater and there is indeed plan for endovenous ablation. Satisfactory relief may be achieved from endovenous ablation alone and not require stab phlebectomy. The requested stab phlebectomy is not reasonable or medically necessary 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 these services have not been met.Therefore, we decided that the Plan does not have to pre-approve stab phlebectomy.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).You asked the Plan to pre-approve IRF care. You say that this is medically necessary.The Plan denied your request. The Plan says the services can be safely received in another setting.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does not require the close intensive supervision of a physician and nursing on an IRF level. The enrollee may benefit from PT and OT but the documentation does not reveal that the enrollee's functional status requires this on an IRF intensive level.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
You asked the Plan to pre-approve SNF services. You say that the enrollee has declined in function, and needs to get back to baseline. The Plan denied your request. The Plan says the enrollee is at her prior level of function, and does not require additional skilled services in an inpatient setting.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF services. Our physician reviewer found that from a nursing perspective, the enrollee received oral medications, and had stable vital signs. There are no identifiable skilled nursing service needs. Regarding rehab services, the enrollee was at a moderate to maximal assist level with functional mobility. The enrollee required varying assist with activities of daily living. There are no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.