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

We decided that the Plan does not have to pre-approve Durolane injection, right knee.

You asked the Plan to pre-approve Durolane injection (J7318). You say that this drug is the most effective treatment. The Plan denied your request. The Plan says the enrollee has not first tried and failed 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 Durolane injection (J7318). Our reviewer says that the drug is not medically reasonable and necessary. Our physician reviewer found the enrollee has not trialed viscosupplemental treatment such as Orthovisc and Monovisc. Step therapy, as outlined by the plan, requires that these be trialed first. The documentation does not outline contraindications or reasons these medications were not considered. Without the support of the documentation, Durolane is not approved as step criteria have not been met. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Durolane injection (J7318) have not been met. Therefore, we decided that the Plan does not have to pre-approve Durolane injection, right knee.
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 the care and services required by this enrollee currently exceeds the clinical capabilities of lower levels of care in this geographical area The Plan denied your request. The Plan says the records do not show that is it medically necessary for the enrollee to be in an LTACH in place of an acute care hospital.

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 there is no documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient 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 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hospital admission for anesthesia for a dental exam, cleaning, and other dental services deemed necessary.

You asked the Plan to pre-approve the hospital admission for anesthesia for dental care. You say that the enrollee needs dental care and is not able to have an exam without anesthesia due to his medical condition and disability. You feel that this should be covered so he can receive necessary dental care. The Plan denied your request. The Plan says this is not a covered service under Medicare.

Medicare generally does not cover dental services. Inpatient hospital care for may be covered only when the dentist's services are covered under Part B. Of note, your Plan does offer a supplemental benefit which goes beyond Medicare coverage, but this does not cover anesthesia or the services of a hospital facility.

The services being requested are for the care and treatment of the teeth and supporting structures. This means that they are considered dental services which are not covered by Medicare. As such, the hospital services can also not be covered by Medicare. Since the dental benefit also does not provide coverage for this, these services are not covered by the Plan. Therefore, we decided that the Plan does not have to pre-approve hospital admission for anesthesia for a dental exam, cleaning, and other dental services deemed necessary.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Grafix prime, per square centimeter (Q4133) and Epifix, per square centimeter (Q4186).

You asked the Plan to pre-approve the wound care products. You say that the wound care products would help prevent infection, help manage pain and prevent further development of new ulcers. The Plan denied your request. The Plan says Epifix and Grafix are considered unproven for treatment of pressure sores.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The rules also say that experimental and investigational devices are not covered. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the wound care products have not been met. Therefore, we decided that the Plan does not have to pre-approve Grafix prime, per square centimeter (Q4133) and Epifix, per square centimeter (Q4186).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve consultation and treatment to be provided by an out of
network (OON) provider.

You asked the Plan to pre-approve the OON consultation and treatment services. You say that you have
ulcerative colitis and prostate cancer. You say that iodine seed implantation and HDR brachytherapy is not
offered through network providers. You say that your provider has recommended you see the requested OON
provider. The Plan denied your request. The Plan says OON care is not medically necessary and there are in
network providers available to treat the enrollee.

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 confirmed that they
have network providers available who can provide the items/services at issue in this appeal. You may contact
the Plan directly for the specific names of these providers. We found no exception that would require the Plan
to pre-approve OON care. Therefore, we decided that the Plan does not have to pre-approve consultation and treatment 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 continued skilled nursing facility (SNF) services.

You asked the Plan to pre-approve continued services. You say that the enrollee needs a week longer to be able to walk on his own. The Plan denied your request. The Plan says the enrollee made minimal progress toward pre-established goals.

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. Continued SNF services beyond July 8, 2021, were 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 from a nursing perspective, the enrollee received oral medications, had stable vital signs, and his lungs were clear. There are no identifiable skilled nursing service needs. Regarding rehab services, the enrollee was at a standby assist to contact guard assist level with functional mobility. He required varying assist with activities of daily living. There are no identifiable skilled therapy service needs. He does not require skilled nursing or therapy services on a daily basis. He does not meet severity of illness or intensity of service criteria for an inpatient 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 continued services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to approve in-network coverage for continued skilled nursing facility (SNF) care in an out of network (OON) facility.

You asked the Plan to approve in-network coverage for the OON SNF care. You say that you do not wish to transfer to any other facility because you believe this will expose you to COVID. You feel that the Plan should allow in-network coverage in the current facility. The Plan denied your request. The Plan says there is a network SNF which does not have COVID patients available. You may transfer to this SNF to receive in-network coverage or remain in the current facility with your OON benefits.

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 approve in-network coverage for 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 approve in-network coverage for these items/services. Therefore, we decided that the Plan does not have to approve in-network coverage for continued skilled nursing facility (SNF) care in an out of network (OON) facility.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an electronic connection, standard remote joystick replacement, and residual limb support accessories.

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 items are not covered.

The Plan must follow Medicare rules. Medicare rules say that wheelchair accessories are covered when specific criteria are met. 

We looked at the file and Medicare rules. The requested electronic connection is not needed because it is already included in the approved power options. There is no separate billing for the standard remote joystick, as it is a column II code that cannot be separately approved. The residual limb support is not needed because the records do not show that the enrollee has an amputated limb. 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 electronic connection, standard remote joystick replacement, and residual limb support accessories.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the diagnostic cast (D0470), the gingival irrigation (D4921 x 2), and the scaling and root planing for 1 to 3 teeth per quadrant (D4342 x 2) provided from December 29, 2020, to December 30, 2020.

You asked the Plan to pay for the diagnostic cast, gingival irrigation, and scaling and root planing. You say that you were advised that you could go to any dentist of your choice. You say that you could not find a dentist that would accept your insurance. You say that your dentist suggested you send a copy of the bill to your insurance. You also say that you submitted claims for services you received in 2021 and have not received any refunds. The Plan denied your request. The Plan says diagnostic cast is not listed as a covered service. The Plan says that gingival irrigation is not listed as a covered service. The Plan says that there is a 50% coinsurance for scaling and root planing. The Plan also says that the cost share was applied correctly per your plan benefits and is your responsibility.

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 diagnostic casts and gingival irrigation are not among those covered under this benefit. Additionally, the cost share was applied correctly to the scaling and root planing per your plan benefits. Cost-sharing is a contractual obligation of the plan and cannot be waived. Therefore, we decided that the Plan does not have to pay for the diagnostic cast (D0470), the gingival irrigation (D4921 x 2), and the scaling and root planing for 1 to 3 teeth per quadrant (D4342 x 2) provided from December 29, 2020, to December 30, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.

You asked the Plan to pre-approve the LTACH services. 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 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 there is no documentation provided necessitating admission to a LTACH. You are receiving appropriate care at the present acute care hospital. You do not require services at the LTACH that are not available at the acute care hospital where you are currently receiving care. There are no services available at the LTACH that you require that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for your diagnosis and condition and are able to be furnished safely and effectively only on an inpatient 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a repeat paravertebral facet joint injection for the enrollee.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the requested procedure has been determined to be not medically necessary.

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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no note of the prior percentage of pain relief at the time of the appointment and request. This request fails to meet the appropriate LCD requirements. 

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 a repeat paravertebral facet joint injection for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Purewick female external catheter system (A9270).

You asked the Plan to pre-approve the Purewick female external catheter system. You say that the enrollee will
benefit from a Purewick external catheter because she is bedridden, has frequent urinary tract infections and
has decubital ulcers. The Plan denied your request. The Plan says this item is not a covered benefit. It is not
medical in nature and it is used for comfort, hygiene and convenience.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered. The rules say that for equipment to be covered, it must primarily serve a medical
purpose.

We looked at the file and Medicare rules. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. Based on this information, we decided that Medicare rules for coverage of the Purewick female external catheter system have not been met. Therefore, we decided that the Plan does not have to pre-approve the Purewick female external catheter system (A9270).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional transportation trips.

You asked the Plan to pre-approve additional transportation trips. You say that you would like the Plan to pre-approve more trips. The Plan denied your request. The Plan says you have utilized the maximum number of transportation trips allowed per year.

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 24 trips per year.

We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional transportation trips.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an MRI scan of the head provided on December 11, 2020, by
an out-of-network provider.

You asked the Plan to pay for an MRI scan of the head. You say that the care at issue was given to the enrollee
in good faith. The Plan denied your request. The Plan says rules for out-of-network care have not been met.

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 requested provider in this case is not a network provider with the Plan. The Plan had network providers
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.

Therefore, we decided that the Plan does not have to pay for an MRI scan of the head provided on December
11, 2020, by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM).

You asked the Plan to pre-approve a Freestyle Libre CGM. You say that this is medically necessary. The Plan denied your request. The Plan says the requirements for coverage have not been met.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results.

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of a Freestyle Libre CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Fasenra pen for the enrollee.

You asked the Plan to pre-approve the pen. You say that this is needed to treat severe asthma. The Plan denied your request. The Plan says the enrollee does not have an eosinophilic phenotype, defined by an elevated peripheral blood eosinophil level of greater than or equal to 300 cells/mcL in the previous 12 months or greater than or equal to 150 cells/mcL at therapy initiation.

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 pen. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found the enrollee has a diagnosis of severe persistent asthma, with frequent exacerbations. The enrollee had improved with Dupoxent, but had to stop because of side effects. Fasenra targets eosinophils and is indicated for patients with eosinophilic asthma. The enrollee reportedly does not have eosinophilia, although no laboratory data are provided.

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 pen have not been met. Therefore, we decided that the Plan does not have to pre-approve a Fasenra pen for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.

You asked the Plan to pre-approve foot orthotics. You say that your right leg is shorter than the left. The Plan denied your request. The Plan says this item is not a covered benefit.

Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. 

Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.