Persius/hicric huggingface dataset:
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 records provided support the need for LTACH care. The Plan denied your request. The Plan says an LTACH admission is not medically necessary at this time.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is currently undergoing treatment at an acute care hospital (ACH) after suffering seizures attributed to hypoglycemia. The enrollee has been receiving total parenteral nutrition (TPN) since December 2019 due to short gut syndrome after a bowel resection. The enrollee continues to receive TPN, but is also taking oral nutrition. The enrollee is not intubated/ventilated. There is no evidence that the enrollee requires services that are not currently available. There is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such a time that no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care needs. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve repairs to a shower chair.
You asked the Plan to pre-approve the shower chair repairs. You say that this is needed for showering and has a torn seat. The Plan denied your request. The Plan says shower chairs are not covered by Medicare so the repair of a shower chair is likewise not covered.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve repairs to a shower chair.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Zarxio (filgrastim-sndz).
You asked the Plan to pre-approve the Zarxio. You say that this drug is necessary. The Plan denied your request. The Plan says the enrollee does require this type of treatment but there is no reason that the preferred drugs cannot be used.
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 Zarxio. Our reviewer says that the requested drug is not considered reasonable and necessary based on step therapy rules. Our physician reviewer found the enrollee has a diagnosis of Agranulocytosis secondary to cancer chemotherapy. The enrollee is being treated for lung cancer. The documentation does not support that the enrollee has tried and failed the required drugs. The documentation does not support that Neupogen (Filgrastim) or Nivestym (Filgrastim-aafi) 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 the Zarxio have not been met. Therefore, we decided that the Plan does not have to pre-approve Zarxio (filgrastim-sndz).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve DUROLANE for the enrollee.You asked the Plan to pre-approve DUROLANE. The Plan denied your request. The Plan says that they did not receive documentation supporting the medical necessity for a step therapy exception.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. Our reviewer says that DUROLANE is not medically reasonable and necessary for the enrollee in this case. The provided medical records do not indicate that the enrollee has tried and failed Orthovisc and Monovisc or that these drugs 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 steptherapy criteria for DUROLANE.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex spacer.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has severe disc degeneration. The requested Vertiflex spacer is considered experimental in nature, as more research is needed to show safety and efficacy. The services are therefore 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 a Vertiflex spacer.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve maxillary partial dentures (CPT D5213).
You asked the Plan to pre-approve the maxillary partial dentures. You say that you need teeth to chew. You say that you are missing the majority of your molars and cannot chew food. The Plan denied your request. The Plan says your benefit for the service in dispute has been exhausted.
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 coverage for maxillary partial dentures is limited to one set every 60 months. The records show that the plan provided coverage for a set of maxillary partial dentures on November 10, 2015. This means that your benefit for maxillary partial dentures is currently exhausted. Therefore, we decided that the Plan does not have to pre-approve maxillary partial dentures (CPT D5213).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for oral exam (D0120) intraoral-periapical x-rays (D0220) bitewing x-rays (D0272) and prophylaxis, cleaning (D1110) provided September 20, 2019.You asked the Plan to pay for the dental services. You say that you had spoken to a plan representative and feel you received incorrect information and an incorrect claim form and feel the services should be paid.The Plan denied your request. The Plan says enrollee's must receive their dental services from an in-network provider.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.The health plan contract specifically says that services are only covered when received by a participating provider.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 for oral exam (D0120) intraoral-periapical x-rays (D0220) bitewing x-rays (D0272) and prophylaxis, cleaning (D1110) provided September 20, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the a home ventilator to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the requested item. You say that the requested supplier providers a respiratory therapist to go into the home as much as needed. The Plan denied your request. The Plan says the requested service is available in-network.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve the a home ventilator 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 Procardia XL for the enrollee.
You asked the Plan to pre-approve Procardia XL. 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 Procardia XL for the enrollee.
Benefits for Procardia XL 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the lumbar spine.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has unspecified dorsalgia. There is no discussion of the pain features. The physical exam did not include a spine or musculoskeletal examination. There is no discussion of medication and conservative treatments that have been trialed. The requested MRI is not reasonable or medically necessary based on the submitted documentation. 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 magnetic resonance imaging (MRI) of the lumbar spine.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core buildup services.You asked the Plan to pre-approve the core buildup services. You say that the enrollee needs a root canal, which was approved. You say that the enrollee will need endo buildup to fill the canal of the tooth once the root canal is completed. You say that you cannot leave this open. You say that this is a standard procedure done with a root canal.The Plan denied your request. The Plan says the requested code is not clinically appropriate.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. Medicare rules also say that procedures should be reported with the CPT code that describes the services performed.Though the Plan offers a dental benefit in excess of Medicare coverage, this benefit is limited to services that are considered necessary. The CPT code you are requesting coverage for is D2950 which is defined as the building up of coronal structure when there is insufficient retention for a separate extracoronal restorative procedure. You advised that the service in dispute was being requested for a treatment plan involving a root canal. The records do not demonstrate that the core buildup services are being requested for use with a crown or other extracoronal procedure.Therefore, we decided that the Plan does not have to pre-approve core buildup services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-sharing forphysical therapy services and an evaluation provided from December 2, 2019 to December 13, 2019.You asked the Plan to waive the cost-sharing forphysical therapy services and evaluation. You say that you were told by the providerthat they were in-network.The Plan denied your request. The Plan says the cost-sharing amounts you are being charged are correct.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 50% coinsurance for physical therapy and $50 copayment for evaluation from an out-of-network provider. The allowed amounts of the physical therapy services total $696.65, resulting in a total coinsurance amount of $348.31. You are also responsible for a $50 copayment for the initial evaluation. Your total cost-sharing obligation is therefore $398.31.You have been asked to pay 50% coinsurance for physical therapy and $50 copayment for evaluation. Physical therapy services and evaluation fall within the "Outpatient Rehabilitation Services" and "Physician/Practitioner Services, Including Doctor's Office Visits" benefit categories. 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.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia.
You asked the Plan to pre-approve Prolia. You say that you want to try this drug. The Plan denied your request. The Plan says you have not first tried and had a contraindication or intolerance to Zoledronic Acid and you do not have a history of osteoporotic fracture
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 reviewer says that the drug is not medically necessary. Our physician reviewer found this appeal considers the request for Prolia for the treatment of osteoarthritis in bilateral knees. The enrollee has not trialed Zoledronic Acid. Step therapy, as outlined by the plan, requires these be trialed first. The documentation does not outline contraindications or reasons these medications were not considered. Without the support of the documentation, Prolia is not approved as step criteria is not 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 Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to waive the copayment for a diagnostic colonoscopy provided by participating provider on November 26, 2019. You asked the Plan to waive the copayment for a diagnostic colonoscopy. You say that polyps were not removed. The Plan denied your request. The Plan says that the correct copayment has been applied. 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. the Plan has failed to provide medical records to verify polyps were removed. Therefore, we decided that the Plan has to waive the copayment for a diagnostic colonoscopy provided by a participating provider on November 26, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the continued inpatient psychiatric care beyond April 30, 2020.You asked the Plan to pre-approve the continued inpatient care. You say that the enrollee requires this level of care.The Plan denied your request. The Plan says there is no need for ongoing inpatient care for the dates in question.The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the continued inpatient care. Our reviewer says that the documentation does not support that the inpatient psychiatric care was medically reasonable and necessary. Our physician reviewer found this 71-year-old male was admitted to the acute inpatient psychiatric hospitalization on February 28, 2020 with Dementia with BehavioralDisturbance. Based upon review the records provided it was not expected this enrollee would improve in a reasonable period of time beyond the dates in question as he was not showing any dangerousness to self or others without aggressive behaviors. It did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the dates in question as he did not have any suicidal or homicidal thoughts, hallucinations or abnormal behaviors. The health plan's denial of continued inpatient psychiatric services appears appropriate. This enrollee did not require inpatient mental health treatment beyond the dates in question as noted above as he was not a danger to himself or others and did not have any illusions, auditory or visual hallucinations. It did not appear that active treatment was taking place beyond the date in question. It did not appear that the services for the dates in question were reasonably expected or medically necessary to improve the patient's condition or for the purpose of diagnosis. 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 continued inpatient care have not been met.Therefore, we decided that the Plan does not have to pre-approvethe continued inpatient psychiatric care beyond April 30, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Symobicort for the enrollee.You asked the Plan to pre-approve this drug. You say that the enrollee needs this for treatment of chronic obstructive pulmonary disease.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 Symobicort 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission and services.
You asked the Plan to pre-approve SNF services. You say that the enrollee would benefit from inpatient therapy to help regain his strength. 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 care in a SNF when the four factors listed above are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF services. Our physician reviewer found that from a nursing perspective, the enrollee had stable vital signs. He tolerated BiPAP, and was treated for congestive heart failure and COPD exacerbation. He had uncomplicated wound care and offloading to his buttocks and posterior thigh. There are no identifiable skilled nursing service needs. Regarding rehab services, the enrollee is at a one-person assist for transfers. Although there are identifiable skilled therapy service needs, the enrollee does not require skilled nursing or therapy services on a 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based filling on tooth #21 (D2391) provided on December 17, 2019.You asked the Plan to pay for the resin-based filling on tooth #21 (D2391). You say that the fillings were medically necessary. The Plan denied your request. The Plan says the benefit is exhausted 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, there is a benefit limit for the fillings. The plan clearly states that only two fillings procedure are covered every calendar year. The records show the Plan paid for two resin-based fillings on tooth #'s 19 and 20 on December 17, 2019 which exhausted the benefit. Therefore, we decided that the Plan does not have to pay for the resin-based fillings on tooth # 21 (D2391) provided on December 17, 2019.