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

We decided that the Plan does not have to pre-approve use of Gamunex-C (intravenous immune globulin or IVIG).
You asked the Plan to pre-approve IVIG. You say that you are appealing based on medical necessity. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because the enrollee does not have a covered indication for IVIG.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use. Medicare rules have also specified certain conditions for which IVIG may be 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 IVIG. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested use of Gamunex-C IVIG. Our physician reviewer found this drug is not Food & Drug Administration (FDA) approved for use in the enrollee's diagnosis. The enrollee does not have a covered indication for this drug. This use of IVIG is not supported by one of the major
drug compendia or by research appearing in a Medicare-approved medical journal. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IVIG have not been met. Therefore, we decided that the Plan does not have to pre-approve use of Gamunex-C (intravenous immune globulin or IVIG).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan has to pre-approve Dexcom G6 glucose monitor

You asked the Plan to pre-approve Dexcom G6 glucose monitor. You say that the item is medically necessary. The Plan denied your request. The Plan says that you do not meet the criteria for this item.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered reasonable and necessary for enrollees with diabetes who meet criteria referenced 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 Dexcom G6 glucose monitor. Our reviewer says that you need this medical item. Our physician reviewer found the elements of the local coverage determination are satisfied and the requested service is recommended.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Dexcom G6 glucose monitor have been met. Therefore, we decided that the Plan has to pre-approve Dexcom G6 glucose monitor.

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: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve CT scan of the abdomen 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 the next imaging study would be due in June 2021.
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 scan. Our reviewer says that the requested scan is medically reasonable and necessary. Our physician reviewer found the enrollee stage 2 papillary renal cell carcinoma treated with radiofrequency ablation in July 2019. A follow up CT scan in June 2020 demonstrated decrease size of the lesion. The enrollee was seen in September 2020 at which time no new issues were identified. The documentation indicates the plan was to repeat the CT scan prior to a visit in six months. In this case in which it is noted that the enrollee also has two additional cancer types, the requested CT scan is consistent with this approach. The reasonableness and necessity of the requested procedure is consistent with the coverage rule. Therefore, the requested CT scan is recommended. 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 CT scan of the abdomen 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 Plan does not have to pre-approve Actemra (J3262).

You asked the Plan to pre-approve Actemra. You say that the drugs are medically necessary. The Plan denied your request. The Plan says the enrollee did not meet the required step therapy drugs.

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 Actemra. Our reviewer says that the service is not medically necessary. Our physician reviewer found the enrollee has not completed the required step therapy for this drug and the documentation does not support that the required step therapy drugs would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Actemra have not been met. Specifically, the enrollee has not met the required step therapy requirements. This means the requested drug is not medically necessary. Therefore, we decided that the Plan does not have to pre-approve Actemra (J3262).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for an ultrasound examination and laboratory testing provided on August 13, 2020.
You asked the Plan to waive the copayments for ultrasound and lab test. You say that these tests were part of your wellness visit. The Plan denied your request. The Plan says the copayment amounts you are being charged is correct. The Plan also says that they have waived the copayment for the lab test performed on August 31, 2020, so this denial is only for the testing provided on August 13, 2020.
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 you must pay $160 copayment for ultrasound and $10 copayment for lab test. For the ultrasound you have only been asked to pay the allowed amount of $102.95, which is less than the $160 copayment. Your total copayment obligation is therefore $112.95. You have been asked to pay less than $160 copayment for ultrasound and $10 copayment for lab test. Ultrasound and lab test fall within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies 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 copayments for an ultrasound examination and laboratory testing provided on August 13, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on June 11, 2020.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the claim was billed incorrectly.

The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT codes describing the component test results. 

We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on June 11, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room (ER) services.

You asked the Plan to waive the copayment for these services. You say that you disagree with the charges. The
Plan denied your request. The Plan says the copayment was applied correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees
must pay a $90 copayment for in-network emergency services.

Review of the file shows that the enrollee received ER services. The enrollee has been asked to pay a $90 
copayment for these services. These services fall within the in-network emergency services benefit category. 
This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. 
This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for the emergency room (ER) services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission and services.

You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says the enrollee is at
or near their baseline level of abilities.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section 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 the enrollee is walking 50 feet with a rolling walker with moderate assistance, is at moderate assist
for transfers, and maximum assist for activities of daily living. There is no report of any other medically
unstable condition. There is no documentation that the enrollee requires the services of a skilled professional
nurse to safely and effectively provide medically necessary and reasonable treatment. Although skilled therapy
services are required, the enrollee does not require skilled services on a daily basis in a SNF 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 services have not been met. Therefore, we decided that the Plan does not
have to pre-approve a skilled nursing facility (SNF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that an IRF admission is medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of an IRF admission.

The Plan must follow Medicare rules. The rules say that an IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

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 that the complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for congestive heart failure and acute on chronic kidney insufficiency. His medical problems are stable. There are no complex nursing or rehabilitation needs. 

The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 

Additionally, there is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the enrollee just underwent major surgery and is incapable of caring for himself. The Plan denied your request. The Plan says the guidelines for coverage of IRF care have not been met. The Plan says that the enrollee can safely receive the services needed 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 in the Medicare rules section. 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 does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for falls and pneumonia and ahs been discharged home with home health care. He continues to have weakness and falls at home. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the testing is not covered.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed above, are not covered.

The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test
solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory
services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve left lower extremity prosthesis to be provided by an
OON provider.

You asked the Plan to pre-approve left lower extremity prosthesis. You say that the enrollee needs this care
from an OON provider. The Plan denied your request. The Plan says there are multiple in-network providers
able to perform the requested services.

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
left lower extremity prosthesis to be provided by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 8 office visits to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve the office visits. You say that you would like reconsideration because you have been seeing this provider for over 30 years and the in-network providers are an hour away from your home. The Plan denied your request. The Plan says with limited exceptions, you must receive your care from 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/services. Therefore, we decided that the Plan does not have to pre-approve 8 office visits 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 Botox.

You asked the Plan to pre-approve Botox. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested Botox is not medically necessary.

The Plan follows Medicare rules. Medicare rules say that Botox is only covered for certain 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 Botox. Our reviewer says that the documentation does not support that the requested Botox is medically reasonable or necessary. Our physician reviewer found the enrollee complains of dysphagia, persistent despite endoscopic dilation on October 21, 2020 and February 3, 2021 of a Schatzki ring. The enrollee's suspected lower esophageal sphincter dysfunction has not yet been fully characterized (e.g. the timed barium esophagram recommended and not pursued). Therefore, the enrollee does not meet criteria for the requested Botox. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Botox have not been met. Therefore, we decided that the Plan does not have to pre-approve Botox.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc-One (J7325.)

You asked the Plan to pre-approve Synvisc-One (J7325). You say that you want the enrollee to be treated with this drug. The Plan denied your request. The Plan says the enrollee has not first tried and had a contraindication or intolerance to Monovisc and Orthovisc.

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 Synvisc-One (J7325). Our reviewer says that the drug is not medically necessary. Our physician reviewer found based on the medical records provided the patient has not tried and failed the required drug(s). Based on the medical records provided there is no indication that the plan's required drug(s) would likely be less effective and/or likely have adverse effects for the patient. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Synvisc-One (J7325) have not been met. Therefore, we decided that the Plan does not have to pre-approve Synvisc-One (J7325.)
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a spinal cord stimulator.

You asked the Plan to pre-approve a spinal cord stimulator. You say that the requested spinal cord stimulator is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested spinal cord stimulator.

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 a spinal cord stimulator. Our reviewer says that the enrollee does not meet criteria for the requested spinal cord stimulator. Our physician reviewer found the enrollee has chronic low back pain with radiculopathy. She is taking Percocet, Diclofenac, methocarbamol, and Gabapentin. She has had Facet joint blocks and epidural steroid injections. She is reported to have had TENS and physical therapy. She has psychiatric clearance for a SCS trial. She does NOT have an evidence-based indication for a SCS trial and she has not had any spine surgery. The request 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 a spinal cord stimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve a spinal cord stimulator.