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

We decided that the Plan does not have to pre-approve ultra-lightweight wheelchair (K0005), for the enrollee.
You asked the Plan to pre-approve the ultra-lightweight wheelchair. You say that the durable medical equipment is medically necessary. The Plan denied your request. The Plan says the notes the Plan has do not show the enrollee needs special adjustments (in the wheels or axles for example) that are not possible in a standard wheelchair.
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 ultra-lightweight wheelchair. Our physician reviewer found based on the medical records provided there is no documentation provided that meets the requirements listed in the Local Coverage Determination (LCD): Manual Wheelchair Bases (L33788) for Medicare coverage for an ultra-lightweight wheelchair (K0005). 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 ultra-lightweight wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve ultra-lightweight wheelchair (K0005), for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Azithromycin.
You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your
request. The Plan says that this is not covered under Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 Azithromycin.
Benefits for this drug 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 Aranesp for the enrollee.
You asked the Plan to pre-approve Aranesp. You say that this is medically necessary for the enrollee. The Plan
denied your request. The Plan says that you do not meet step therapy criteria.
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 Aranesp. Our reviewer says that
Aranesp is not medically reasonable and necessary for the enrollee in this case. The patient has not tried and
failed Retacrit. There is no documentation provided indicating that Retacrit would likely be less effective
and/or likely have adverse effects for the enrollee. Our physician reviewer found that the enrollee's condition
does not meet step therapy criteria for Aranesp.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Aranesp have not been met. Therefore, we decided that the Plan does not have
to pre-approve Aranesp for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 6 additional physical therapy visits.
You asked the Plan to pre-approve 6 additional physical therapy visits. You say that additional therapy is required due to multiple joint involvement, high fall risk and recent neck surgery. You say that you are requesting additional visits due to the severity of limitations. The Plan denied your request. The Plan says additional visits are not reasonable and necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve 6 additional physical therapy visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the enrollee has had extensive therapy and should be versed in a home exercise program. Our reviewer says that the unique skills of a professional therapist are not required to safely and effectively provide ongoing treatment. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 6 additional physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 6 additional physical therapy visits.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia.
You asked the Plan to pre-approve Prolia. The Plan denied your request. The Plan says the enrollee does not
have a history of osteoporosis-related fracture, or has tried and failed Zoledronic acid.
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 Prolia. Our physician reviewer found
that Prolia is being requested for the treatment of age related osteoporosis without current pathological fracture.
The documentation does not support a history of an osteoporotic fracture or previous treatment,
contraindication, or intolerance to Zoledronic acid. Step therapy, as outlined by the plan, requires this
documentation. Without the support of the documentation, Prolia is not approved.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to
pre-approve Prolia.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied
your request. The Plan says the stay 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 care. Our reviewer says that daily
skilled services are not necessary. Our physician reviewer found there is no required skilled nursing services
are identified. This patient requires skilled therapy services, i.e., are the specialized skill, knowledge and
judgment of a qualified therapist required to safely and effectively provide medically necessary and reasonable
treatment, but not daily. It is not medically reasonable and necessary to provide these skilled nursing or skilled
therapy services (or a combination of these services) on a "daily basis". This patient 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 care have not been met. Therefore, we decided that the Plan does not have
to pre-approve SNF care.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vascepa for the enrollee.
You asked the Plan to pre-approve this drug. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says that this is not covered under 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 Vascepa for the enrollee.
Benefits for this drug 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 continued inpatient psychiatric services.
You asked the Plan to pre-approve continued services. You say that the enrollee is at high risk for relapse into
psychosis. The Plan denied your request. The Plan says the enrollee is medically stable and does not require
24-hour care.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the
patient requires active treatment.
Continued inpatient services beyond August 19, 2020 was requested. 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 services. Our physician reviewer found that active treatment was
not taking place. It did not appear that the services for the dates in question were reasonably expected or
medically necessary to improve your condition, or for the purpose of diagnosis. The services were supervised
and evaluated by a physician. Based upon review the records, you could be treated in a lesser restrictive setting
as you were not showing any suicidal or homicidal ideation, auditory or visual hallucinations, delusions, and
were not showing any behaviors or aggression being cooperative and compliant while not showing any acute
threats to safety.
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 services have not been met. Therefore, we decided that the Plan does
not have to pre-approve continued inpatient psychiatric services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Lupron Depot.
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.
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 a diagnosis of
unspecified endometriosis.She has not tried and failed the Plan's required drugs of non-steroidal anti-inflammatory
drugs (NSAIDs) and oral contraceptives. The records do not show that the required drugs would
be contraindicated or less effective; therefore, the Lupon Depot 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 Lupron Depot.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Procrit (J0885).
You asked the Plan to pre-approve the Procrit. You say that you would like reconsideration because this drug is medically necessary. The Plan denied your request. The Plan says the member does not meet step-therapy exception criteria.
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 Procrit. Our reviewer says that there is no evidence that the enrollee is allergic to or intolerant of Retacrit. There is no evidence that the enrollee has tried and not responded to Retacrit. There is no documentation as to why Retacrit would not be expected to be safe and effective for the enrollee. Our physician reviewer found the requested Procrit is not shown to be currently medically necessary and 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 Procrit have not been met. Therefore, we decided that the Plan does not have to pre-approve Procrit (J0885).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental extraction and anesthesia services.
You asked the Plan to pre-approve the dental extraction and anesthesia services. You say that you were in the hospital from your mouth being full of infections. You say that you passed out from infection and that your mouth is so swollen you cannot eat. You say that you are in a lot of pain and want the teeth gone. You say that your mouth is still numb at the bottom and when you try to chew you cute the insides of your mouth. The Plan denied your request. The Plan says the enrollee's benefit limit for dental extractions has been reached for the 2020 plan year. The Plan says that the requested anesthesia services are not covered benefits under the enrollee's dental plan.
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, the benefit for dental extraction services is limited to 2 per calendar year. The records show that you were approved coverage for the extraction of tooth #12 and #28 on August 13, 2020. This means that the dental extraction benefit for the 2020 calendar year has been exhausted. The benefit for anesthesia is limited to when necessary with a covered service. Because the dental extractions being requested are not covered, the anesthesia being requested is also not covered. Therefore, we decided that the Plan does not have to pre-approve dental extraction and anesthesia services.
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 OON services. You say that you have seen the requested provider
before. The Plan denied your request. The Plan says there are multiple providers in network 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 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network imaging services provided to the enrollee on
February 27, 2020.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your
request. The Plan says the enrollee did not have prior authorization for out of network care.
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 pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care. The Plan contract says that outpatient diagnostic services
required referral or prior authorization.
The 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. The Plan did not pre-approve the service at issue. We
found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan
does not have to pay for out of network imaging services provided to the enrollee on February 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Kyphoplasty procedure.
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says there is
no pain specific to vertebral fracture.
The Plan follows Medicare rules. Medicare rules say that vertebral augmentation is only covered under certain
medical indications.
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 services. Our physician
reviewer found that the magnetic resonance imaging does not show an acute fracture. Recent literature does not
support kyphoplasty for fracture management over placebo. Therefore, the requested kyphoplasty is not
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 the requested services have not been met. Therefore, we decided that the Plan
does not have to pre-approve a Kyphoplasty procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve diabetic supplies to be provided by a non-preferred
brand.
You asked the Plan to pre-approve the requested supplies. You say that the enrollee would like to keep using
the current strips since she is doing well. The Plan denied your request. The Plan says non-preferred brands are
not covered.
Medicare rules say that plans can require enrollees to get care from network providers. The rules say that plans
may limit the DME to only those preferred brands and manufacturers.
The requested brand in this case is not a preferred brand. The Plan has preferred brands available who can
provide the items at issue in this appeal. We found no exception that would require the Plan to pre-approve
these items. Therefore, we decided that the Plan does not have to pre-approve diabetic supplies to be provided
by a non-preferred brand.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Repatha Sureclick.
You asked the Plan to pre-approve Repatha. You say that the enrollee is at a greater risk of having a myocardial
infarction. The Plan denied your request. The Plan says this drug is not covered for the enrollee's condition 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 Repatha Sureclick.
Benefits for Repatha 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-approve the requested durable medical equipment. 
 
You asked the Plan to pre-approve the durable medical equipment. The Plan denied your request. The Plan says 
the enrollee must receive care from in-network providers with the exception of emergency or urgent care, or if 
the care cannot be provided with an in-network provider, which requires prior authorization from the plan. 
 
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 the 
requested durable medical equipment.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for Zilretta.
You asked the Plan to pay for Zilretta. You say that the Zilretta is medically necessary. 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 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 pay for Zilretta. Our reviewer says that Zilretta is not medically necessary. Our physician reviewer found according to the literature, the efficacy and safety of repeat Zilretta injections has not been established. As such, the request for repeat Zilretta injections is not shown to be 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 Zilretta have not been met. Therefore, we decided that the Plan does not have to pay for Zilretta.
Appeal type: Drugs
Decision: Unfavorable

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