Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvedental extractions to be performed by an oral surgeon.You asked the Plan to pre-approvethe oral surgeon services. You say that your tooth is broken and needs to be extracted. You are at risk for infection due to your heart condition.The Plan denied your request. The Plan says while this service may be necessary, your plan does not cover the services of an oral surgeon under the dental benefit.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, coverage is limited to services performed by general dentists.Therefore, we decided that the Plan does not have to pre-approvedental extractions to be performed by an oral surgeon.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approve diabetic test strips.You asked the Planto pre-approvethe test strips. You say that the enrollee has tried other test strips in the past and was confused. She needs to use test strips she is comfortable with.The Plandenied your request. The Plansaysthere is no evidence that the enrollee has received a supply of the preferred brand and has been provided training on use. There is no medical condition noted which requires the use of the non-preferred brand.The Plan must follow Medicare rules. Medicare rules say that plans may restrictDME coverage to certain brands as long as non-preferred brands are available when medically necessary.There is no evidence presented for a medical needs for the non-preferred brand. This is a enrollee preference which is not an exception to the brand restriction.Therefore, we decided that the Plandoes not haveto pre-approve the preferred diabetic test strips.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveEntresto tab 24-26mg for the enrollee.You asked the Planto pre-approvethe drug. You say that this is medically necessary.The Plandenied your request. The Plansaysthis is not a covered benefit.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 Plandoes not haveto pre-approveEntresto tab 24-26mg for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the co-insurance for periodic oral exam (D0120) and prophylaxis (D1110) provided on September 4, 2019.You asked the Plan to waive the co-insurance for the dental services. You say that you went to your dentist of 40 years  and you assumed your cleaning and exam was covered 100% but you received a bill of $107 since your plan pays only $30 for out of network coverage.The Plan denied your request. The Plan says the correct cost share was applied.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such ascopayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 50% coinsurance for out of network providers. Providers are paid based on the maximum allowable charge. You may be billed by the out of network provider for any amount greater than the payment made by the plan to the provider. You have been asked to pay 50% coinsurance for the dental services. The services fall within the Dental 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 co-insurance forperiodic oral exam (D0120) and prophylaxis (D1110) provided on September 4, 2019.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a PET/CT scan for the enrollee.
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your request. The Plan says that there is not enough clinical information to support this request.
The Plan must follow Medicare rules. Medicare rules say that PET 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 scan. Our reviewer says that the requested scan is medically reasonable and necessary. Our physician reviewer found PET/CT is occasionally indicated for non-oncologic evaluation including indolent or smoldering infection. Since the CT findings related to the sternum are equivocal with chronic or indolent osteomyelitis in the differential PET/CT is reasonable and necessary in this case since therapeutic decisions will be impacted depending on the metabolic activity in correlation with the recent CT findings in the sternum. 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 scan have been met. Therefore, we decided that the Plan has to pre-approve a PET/CT scan 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Romiplostim.
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 records show that you were recently treated with other medications, and they are
helping your condition.
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 the drug. Our reviewer says that the
requested drug is not medically reasonable or necessary. Our physician reviewer found based on the provided
medical records romiplostim is not medically reasonable and necessary for the patient at this time.
Romiplostim should be used only in patients with immune thrombocytopenic purpura (ITP) whose degree of
thrombocytopenia and clinical condition increases the risk for bleeding. Romiplostim should not be used in an
attempt to normalize platelet counts. Romiplostim is not indicated for the treatment of thrombocytopenia due to
myelodysplastic syndrome (MDS) or any cause of thrombocytopenia other than ITP.
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 Romiplostim.
Appeal type: Imaging
Decision: Favorable

We decided that the Planhasto pre-approveCT scan of the abdomen and pelvis for the enrollee.You asked the Planto pre-approvethe scan. You say that this is medically necessary.The Plandenied your request. The Plansaysthatthe records show thatthe same study or a test like may have been done.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 tocarefully 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 scan. Our reviewer says that the requested scan is medically reasonable and necessary. Our physician reviewer found a review of this enrollee's lab values shows elevated CRP (13.9) and ESR (67). Together with the history of unintended significant weight loss and a prior abnormal chest CT in July, 2019 there is valid indication for CT of the chest, abdomen and pelvis. Also of note is a prior ultrasound which showed splenomegaly.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 scan have been met.Therefore, we decided that the Planhas to pre-approveCT scan of the abdomen and pelvis for the enrollee.If the Plandoes 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 toreview. The Plan has to show us the mistake and/orsend 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve MSH6 full sequence genetic analysis testing.You asked the Plan to pre-approvegenetic tests. You say that you are appealing based on medical necessity.The Plan denied your request. The Plan says the denial of authorization for these tests is correct, because the enrollee has no personal history of cancer and therefore these tests are statutorily excluded from Medicare coverage.The Plan follows Medicare rules. Medicare rules say that testing of genetic carriers who are unaffected with an applicable cancer is not a Medicare benefit and is statutorily excluded from coverage.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 genetic tests. Our reviewer says that the enrollee does not meet the Medicare criteria for this testing. Our physician reviewer found the enrollee has a strong family history of cancer suggestive of an inherited risk, but no personal history of malignancy. Without a personal history of malignancy, Medicare coverage criteria is not met for these tests. Therefore, the requested testing 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 genetic tests have not been met.Therefore, we decided that the Plan does not have to pre-approveMSH6 full sequence genetic analysis testing.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forocclusal adjustment-limited (D9951) provided by "the doctor" August 27, 2019.You asked the Plan to pay forthe dental services. You say that all your dental charges are connected to a bad fall on stairwell back in August.The Plan denied your request. The Plan says this service is not a covered benefit.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Services not listed as a covered service is not covered by the plan. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forocclusal adjustment-limited (D9951) provided by "the doctor" on August 27, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe medical services to be provided by out of network provider.You asked the Plan to pre-approve the cardiology services. You say that the member would like to continue seeing this provider as they have an established history and report. The Plan denied your request. The Plan says this provider is out-of-network and there are in-network providers available.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 pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers availablewho 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 the medical services to be provided by out of network provider.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approve admission to a long term acute care hospital (LTACH) for the
enrollee.
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied
your request. The Plan says that care can be received in another setting, such as home, a long-term care facility,
or other outpatient setting.
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. Our doctor found that the incorrect records were supplied by the plan. The plan
did not substantiate their denial. Therefore, we decided that the Plan has to pre-approve admission to a long
term acute care hospital (LTACH) 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 Plandoes not haveto pre-approveZarxio (filgrastim biosimilar) treatments.You asked the Planto pre-approvethe Zarxio treatments. You say that you feel that you need to stay on this drug to prevent being hospitalized.The Plandenied your request. The Plansaysthe enrollee is on a low risk regimen and does not appear to require this drug to address neutropenia.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 the Zarxio treatments. Our reviewer says that the documentation does not support that the requested treatment is reasonable and necessary. Our physician reviewer found this review relates to continuation of the use of Zarxio for a 78 year old woman being treated with Ibrance and Letrozole for breast cancer with bone metastases. Zarxio is indicated for the prevention of neutropenic fever in patients with significant incidence of severe neutropenia with fever. The enrollee hasbeen on the drug since at least 6/2018. The notes indicate the dose of Ibrance was reduced due to leukopenia and gastrointestinal symptoms. Her white blood count on day 1 of the 13 cycle of treatment was 2,700 with absolute neutrophils of 2,000. Per the FDA label, the risk of febrile neutropenia from Ibrance is 1.8%. This is not consistent with high or intermediate risk of neutropenic fever as defined by the NCCN Guidelines Version 1.2020 Management of Neutropenia. The definition of high risk is >20% and of intermediate risk is 10-20%(page MGF-1).Therefore there is not significant risk of neutropenic fever. There is no indication the enrollee has had neutropenic fever so secondary prophylaxis is also not supported.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 Zarxio treatments have not been met.Therefore, we decided that the Plandoes not haveto pre-approveZarxio (filgrastim biosimilar) treatments.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea total of 36 psychotherapy sessions (20 in addition to the 16 previously approved).You asked the Planto pre-approvethe 20 additional sessions. You say that you need to have all of the requested sessions because you feel that you will lose the stability you have gained without them.The Plandenied your request. The Plansays16 sessions is sufficient to continue this phase of treatment. If toward the end of the 16 sessions, it is felt that more are necessary, a new request can be made.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 20 additional sessions. Our reviewer says that the additional sessions are not found to be reasonable and necessary in this case. Our physician reviewer found this 54-year-old female is requesting authorization of additional 20 visits with her contracted therapist. This patient is being treated for Borderline Personality Disorder, Major Depressive Disorder, Recurrent in Partial Remission and Binge Eating Disorder, Mild. Based on review the records provided, it is noted that this patient had improvement in symptoms. Her depressive, anxiety, instability feelings depend on emotional support from individuals around her. Based on review the records provided it does not appear this patient requires additional treatment sessions as mentioned the documentation shows this patient to have improvement and that her symptomatology is based on people around her. The previously approved number ofsessions appears to be sufficient.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 20 additional sessions have not been met.Therefore, we decided that the Plandoes not haveto pre-approvea total of 36 psychotherapy sessions (20 in addition to the 16 previously approved).
Appeal type: SNF
Decision: Unfavorable

Medicare rulesThe rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 CFR 422.101.The rules say that Medicare pays for care in a skilled nursing facility (SNF) when all of the following four factors are met:1. The patient requires skilled nursing or skilled rehabilitation services;2. The patient requires these services on a daily basis;3. As a practical matter, the daily skilled services can be provided only on an inpatient basis in a SNF; and4. The services are reasonable and necessary for the treatment of the patient's illness or injury or the services must be needed to establish a safe and effective maintenance program or to prevent the patient's condition from getting worse. You can find these rules at 42 CFR 409.31 and in the Medicare Benefit Policy Manual, Chapter 8, Section 30.  The rules say that custodial care is not covered. Custodial care is personal care for a person who does not need ongoing care from trained medical or paramedical staff. Custodial care serves to help with the activities of daily living. This means the care includes help in walking, getting in and out of bed, bathing, dressing, feeding, and using the toilet. Fixing meals and taking charge of medicine that usually can be self-administered are also custodial care services. You can find this rule in the Medicare Benefit Policy Manual, Chapter 16, Section 110.If you want to read these Medicare rules, you can go to this web site www.medicareappeal.com.The Plan contract says that the Plan covers items and services in accordance with Medicare rules.  Explanation of decisionWe decided that the Plan does not have to pre-approve SNF admission.You asked the Plan to pre-approve the SNF admission. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the 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 careis not covered.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the member's condition would not be expected to deteriorate with services provided on a less than 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 the SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF admission
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvethe OneTouch Ultra Blue test strips for the enrollee.You asked the Planto pre-approvethe strips. You say that this is medically necessary.The Plandenied your request. The Plan says the preferred meters and test strips include: meters and test strips marketed by Roche (e.g. Accu-Chek Aviva Plus, Accu-Chek Guide, Accu-Chek Guide Me) or Trividia Health (e.g. TrueMetrix, TrueTrack).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 denyingthe request to pre-approve the strips. Our reviewer says that the requested brand is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is noted to have type II diabetes, for which she takes two typesof oral medication. The enrollee has been testing her blood sugar twice daily, but has been encouraged to test her blood sugar thrice daily. There is no documentation as to why the enrollee needs a specific brand of meter. The plan appears to cover several meters, any one of which should be suitable for the enrollee. The documentation does not support that the non-preferred meter is medically necessary or reasonable.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 strips have not been met.Therefore, we decided that the Plandoes not haveto pre-approvethe OneTouch Ultra Blue test strips for the enrollee.