Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Freestyle Lite test strips.
You asked the Plan to pre-approve the test strips. The Plan denied your request. The Plan says this brand of test strips is not covered.
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 test strips and monitors must be obtained from preferred vendors Accu-Chek and OneTouch. Test strips and monitors from any other vendor will not be covered. You are requesting diabetic Freestyle Lite test strips. Test strips and monitors must be obtained from preferred vendors Accu-Chek and OneTouch. As the requested test strips are not from a preferred vendor, they are not covered. Therefore, we decided that the Plan does not have to pre-approve Freestyle Lite test strips.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve a non-invasive home ventilator for the enrollee.
You asked the Plan to pre-approve these services. You say that the enrollee will benefit from a non-invasive ventilator. The Plan denied your request. The Plan says that that this is not medically necessary.
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. 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 a home ventilator is medically reasonable and necessary. The enrollee has advanced COPD and is now positive airway pressure dependent. Patient at very high risk for readmission. There is ample documentation of the advanced nature of the patient's advanced lung disease and a non-invasive home ventilator is indicated. Our physician reviewer found that the enrollee's condition meets criteria for a home ventilator. 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 been met. Therefore, we decided that the Plan has to pre-approve a non-invasive home ventilator for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an inpatient admission for drug toxicity for the enrollee.
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 inpatient admission for drug detox is covered when 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee was admitted to the hospital with lithium toxicity. She was transferred to the psychiatric unit for initiation of mood stabilization medication. It is not expected that she would improve in a reasonable period of time, as she is not showing dangerousness to herself or others. She has no delusions or auditory and visual hallucinations or aggressive behaviors. The acute inpatient level of care 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-approve an inpatient admission for drug toxicity for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient behavioral health services.
You asked the Plan to pre-approve the services. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 inpatient care is not medically reasonable and necessary. Our physician reviewer found that the enrollee does not appear to require inpatient mental health treatment beyond the date in question as she is not a danger to herself or others and does not have any auditory or visual hallucinations while being cooperative with treatment. It does not appear that active treatment is taking place beyond the date in question. It does not appear that the services are reasonably expected to improve the enrollee's condition or for the purpose of diagnosis beyond the date in question. 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 inpatient behavioral health services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Belbuca for the enrollee.
You asked the Plan to pre-approve Belbuca. The Plan denied your request. The Plan says drug coverage is limited to Medicare Part B covered 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 Belbuca for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve non-emergent ambulance services.
You asked the Plan to pre-approve non-emergent ambulance services. You say that this is medically necessary. The Plan denied your request. The Plan says the documentation does not show that the enrollee could not use another form of transportation.
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. 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 non-emergent ambulance services. Our reviewer says that the records do not support need for ambulance transportation. Our physician reviewer found there is nothing in documentation that supports need for ambulance transportation. The enrollee can sit in wheelchair and is not unstable from cardiopulmonary standpoint. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of non-emergent ambulance services have not been met. Therefore, we decided that the Plan does not have to pre-approve non-emergent ambulance services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve infusion services. You say that your doctor suggested that you go to this provider. The Plan denied your request. The Plan says the denial of authorization for these services is correct, because this provider is out-of-network with the Plan and you can be treated by an in-network provider. 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 and services. Therefore, we decided that the Plan does not have to pre-approve the medical services 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 Atezolizumab (Tecentriq) with Bevacizumab (Avastin) for the enrollee.
You asked the Plan to pre-approve the requested drugs. The Plan denied your request. The Plan says there is no support for Tecentriq with Avastin in previously treated hepatocellular carcinoma.
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 requested drugs. Our physician reviewer found that the enrollee has hepatocellular cancer (HCC), is already being treated with Lenvima, and has performance status 3. The requested drugs are not FDA approved to treat HCC. The drugs are not supported by any of the CMS approved compendia to treat HCC. The requested use is not listed as not indicated, not supported or not recommended in any of the compendia. Therefore, the requested drug is not considered 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 requested drugs have not been met. Therefore, we decided that the Plan does not have to pre-approve Atezolizumab (Tecentriq) with Bevacizumab (Avastin) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an oxygen conserver (A9270). You asked the Plan to pre-approve an oxygen conserver. The Plan denied your request. The Plan says this is not a covered benefit. The Plan must follow Medicare rules. Medicare rules say that a status indicator of "N" indicates that the item/service in question is not covered by Medicare. We looked at the file and Medicare rules. The requested oxygen conserver, represented by code A9270 is assigned a status indicator of "N" under the physician fee schedule, which means this is a non-covered item. Additionally, the definition of the requested code is "Non-covered item or service". Based on this information, we decided that Medicare rules for coverage of an oxygen conserver have not been met. Therefore, we decided that the Plan does not have to pre-approve an oxygen conserver (A9270).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve medical services to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the services. The Plan denied your request. The Plan says the services are available in-network. Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to 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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve medical services to be provided by an out-of-network (OON) provider.
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 you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says the requested LTACH services are not medically necessary.
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 the enrollee is currently undergoing treatment at an acute care hospital (ACH) for recurrent respiratory failure, in the setting of morbid obesity. The enrollee was intubated/ventilated and subsequently received a tracheotomy. The enrollee has been weaned from the ventilator. It is unclear if decannulation is expected, given her ongoing risk for recurrent respiratory compromise and long-term need for nighttime ventilator assistance. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and 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 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of ZILRETTA.
You asked the Plan to pre-approve ZILRETTA. You say that you want to go another 6 or 7 months without knee replacement surgery due to the coronavirus. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because repeat administration of ZILRETTA is considered investigational.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 ZILRETTA. Our reviewer says that you do not meet the Medicare criteria for the requested use of ZILRETTA. Our physician reviewer found the Food and Drug Administration (FDA) indicates that a ZILRETTA injection for the management of osteoarthritis pain of the knee is not intended for repeat administration. The efficacy and safety of repeat ZILRETTA administration has not been demonstrated. Therefore, the documentation submitted does not support that ZILRETTA is medically reasonable and necessary, nor safe and effective for treatment of your condition 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 ZILRETTA have not been met. Therefore, we decided that the Plan does not have to pre-approve use of ZILRETTA.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an oncologic gynecology consultation to be provided by an out of network (OON) provider. You asked the Plan to pre-approve the (OON) oncologic gynecology consultation. You say that you had a surgery in early March in which many masses were found in your abdomen. You feel that you should be allowed a second opinion. The Plan denied your request. The Plan says your network has several tertiary (higher expertise) providers who can provide a second opinion. As there is no deficiency in network providers, referral to the OON facility is not necessary. 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 an oncologic gynecology consultation to be provided by an out of network (OON) provider.
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. The Plan denied your request. The Plan says that there are no noted daily skilled complex nursing or therapy needs.
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 the enrollee's condition does not meet Medicare criteria for 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 skilled nursing facility (SNF) services for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a wheelchair ramp.
You asked the Plan to pre-approve a wheelchair ramp. You say that you are having a very hard time getting into her house without a ramp. The Plan denied your request. The Plan says that 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 wheelchair ramp.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shoe insert.
You asked the Plan to pre-approve a shoe insert. You say that you need this because you walk with a limp due to a different in leg length. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that shoe inserts are only covered if they are on a shoe that is an integral part of a covered brace and if they are medically necessary for the proper functioning of the brace. We looked at the file and Medicare rules. The documentation provided does not show that requested shoe insert will be part of a shoe that is an integral part of a covered leg brace. Based on this information, we decided that Medicare rules for coverage of a shoe insert have not been met. Therefore, we decided that the Plan does not have to pre-approve a shoe insert.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia (denosumab) injections.
You asked the Plan to pre-approve the Prolia injections. You say that oral bisphosphonate have been used for five years and it is felt that Prolia is now medically indicated. The Plan denied your request. The Plan says there is no evidence that the use of the preferred drug would be less effective or harmful.
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 Prolia injections. Our reviewer says that the requested drug is not considered medically reasonable and necessary based on step therapy rules. Our physician reviewer found the enrollee is a 72 year old female who has had a recent bone density study showing osteopenia - Prolia is requested. There is no evidence in the record that the enrollee has tried/failed the required drug, IV zoledronic acid. The provided medical records do not indicate 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 the Prolia injections have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia (denosumab) injections.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a tier exception for .5mg/2ml Budesonide.
You asked the Plan to pre-approve the tier exception. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says Budesonide is covered under Medicare Part B so tier exceptions do not apply.
The Plan must follow Medicare rules. Medicare rules say that tiered cost-sharing means a process of grouping Part D drugs into different cost sharing levels within a Part D sponsor's formulary. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the tier exception have not been met. Specifically, this drug is covered under Medicare Part B. Medicare Part B drugs are not eligible for tier exceptions. Therefore, we decided that the Plan does not have to pre-approve a tier exception for .5mg/2ml Budesonide.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation for the enrollee.
You asked the Plan to pre-approve additional transportation. You say that the enrollee needs ride assistance to attend all of her appointments. The Plan denied your request. The Plan says the enrollee's benefit only allows 48 trips for this service.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 48 one-way trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the enrollee has exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation for the enrollee.