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

We decided that the Plan has to pre-approve Zilretta (J3304).
You asked the Plan to pre-approve Zilretta. You say that the enrollee received an injection 4 month ago and it
was beneficial until recently. You say that this drug lasts much longer than a standard corticosteroid. The Plan
denied your request. The Plan says that that only 1 lifetime dose may be approved per the Food and Drug
Administration.
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 Zilretta. Our reviewer says that Zilretta
is medically necessary. Our physician reviewer found Zilretta is indicated for the enrollee's diagnosis per the
Food and Drug Administration (FDA). The reviewer found that the product label does not indicate the efficacy
and safety of repeat administration of Zilretta have not been demonstrated. Therefore, the reviewer found that
the requested drug is medically reasonable and 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 Zilretta have been met. Specifically, the requested drug is indicated for the
enrollee's diagnosis per the FDA. Therefore, we decided that the Plan has to pre-approve Zilretta (J3304).
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a vertiflex superion device.
You asked the Plan to pre-approve a vertiflex superion device. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.
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 vertiflex superion device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the vertiflex device is experimental. More research is needed to show safety and efficacy of the device.
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 vertiflex superion device have not been met. Therefore, we decided that the Plan does not have to pre-approve a vertiflex superion device.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ilumya.
You asked the Plan to pre-approve Ilumya. You say that this drug is medically necessary for the enrollee's
condition. The Plan denied your request. The Plan says step therapy criteria have not been met.
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 Ilumya. Our reviewer says that the
requested drug is not medically reasonable and necessary. Our physician reviewer found that in this case, the
record indicates that the enrollee has psoriasis. The requested medication is a new start. The provided records
do not indicate that the enrollee has tried and failed the plan's preferred step one alternative. The record does
not indicate that the enrollee has a contraindication to or would have an adverse effect from the plan's preferred
step one alternative. The elements of the coverage criteria are not satisfied. The requested service cannot be
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 Ilumya have not been met. Therefore, we decided that the Plan does not have to
pre-approve Ilumya.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the guided tissue regenerations (D4266), surgical placements of implant bodies: endosteal implants (D6010), bone grafts at time of implant placements (D6104), and semi-precision attachments (D6192) provided on February 18, 2021.
You asked the Plan to pay for the guided tissue regenerations, endosteal implants, bone grafts, and semi-precision attachments. You say that you needed these procedures so you could have dentures to eat with. The Plan denied your request. The Plan says these services are not covered benefits under your 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 requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the guided tissue regenerations (D4266), surgical placements of implant bodies: endosteal implants (D6010), bone grafts at time of implant placements (D6104), and semi-precision attachments (D6192) provided on February 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the eye exam, eye evaluation and refraction provided on March 24, 2021.
You asked the Plan to pay more for the eye exam, eye evaluation and refraction. You say that last year you would have paid $75 out-of-pocket, but you were billed $209.77. You say that this is difficult for you to pay and the claim should be considered. The Plan denied your request. The Plan says the claim reprocessed to pay for the eye exam and eye evaluation with a $35 copayment. The refraction remains denied as a non-covered benefit.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a medical eye exam with a $35 copayment. The Plan only covers a refraction with a routine eye exam from a network provider. We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for additional coverage of the eye exam, eye evaluation and refraction have not been met. Specifically, the Plan paid for the eye exam and eye evaluation leaving a $35 copayment. The refraction remains denied as it was not done with a routine eye exam from the Plan's supplemental vision provider. Therefore, we decided that the Plan does not have to pay more for the eye exam, eye evaluation and refraction provided on March 24, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the lumbar.
You asked the Plan to pre-approve an MRI of the lumbar. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
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 an MRI of the lumbar. Our reviewer says that the services are not medically necessary. Our physician reviewer found history includes spinal stenosis but no details as to duration, plain films or other info. Recent physical exam had negative bilateral straight leg raise. Normal lower extremity strength and no absent reflexes. There are no red flags mandating immediate MRI without first attempting conservative management including physical therapy for 6 weeks. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an MRI of the lumbar have not been met. Therefore, we decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the lumbar.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient skilled nursing facility (SNF)
care provided from December 1, 2020, through December 31, 2020.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to
the services provided.
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 he must pay
a $0 copayment each day, for days 1 to 20 and a $160 copayment each day, for days 21-56 for skilled nursing
facility care. Additionally, enrollees pay a $0 copayment for additional Medicare-covered days, up to 100 days.
The enrollee has been asked to pay $2,947.80 for the inpatient skilled nursing facility care provided. This
amount is less than the applicable copayment of ($160 copayment x 27 days=$4,320) for days 30-56 in a
skilled nursing facility as the enrollee had reached the out-of-pocket maximum for the 2020 calendar year. The
enrollee previously received skilled nursing care in this facility from November 2, 2020, through November 30,
2020. 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 when he enrolled in the Plan.
Therefore, we decided that the Plan does not have to waive the copayment for the inpatient skilled nursing
facility (SNF) care provided from December 1, 2020, through December 31, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient hospital care.

You asked the Plan to pre-approve acute inpatient hospital care. You say that the enrollee was approved for a
right reverse total should arthroplasty and will need inpatient admission after surgery. The Plan denied your
request. The Plan says there is no documentation provided to support the expectation the enrollee will require a
greater than 2 midnight stay.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases,
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or
more.

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 acute inpatient hospital care. Our
reviewer says that the documentation does not support that the criteria for inpatient payment are met in this
case. Our physician reviewer found the enrollee is approved for a right reverse total shoulder arthroplasty. The
record does not document that the treating physician has a reasonable expectation of a length of stay spanning 2
or more midnights.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the
Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of Botox (botulinum toxin).

You asked the Plan to pre-approve Botox. You say that Botox is used to open the pyloric muscle to treat gastroparesis. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because studies have not proven that this is helpful for the enrollee's condition.

The plan follows Medicare rules. Medicare rules state that Botox may be covered for Food & Drug Administration (FDA) labeled indications or for certain specified off-label 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 enrollee does not meet the Medicare criteria for Botox. Our physician reviewer found the enrollee has a diagnosis of gastroparesis. The Food & Drug Administration (FDA) has not stated that the requested drug is indicated for this condition. This diagnosis is not a covered condition in the Medicare coverage determination. Therefore, this service cannot be 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 Botox have not been met. Therefore, we decided that the Plan does not have to pre-approve use of Botox (botulinum toxin).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy provided by an out-of-network provider on January 14, 2021.

You asked the Plan to pay for physical therapy. You say that authorization was obtained with the approval date of January 7, 2021. You say that other claims with the approval dates were already paid. The Plan denied your request. The Plan says prior authorization for out-of-network services was not obtained.

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's authorization for physical therapy was not for this provider. 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 physical therapy provided by an out-of-network provider on January 14, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular risk assessment panel provided on April 22, 2021.

You asked the Plan to pay for the cardiovascular risk assessment panel. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. Cardiovascular risk assessment panels are only covered for certain indications. 

While cardiovascular risk assessment panels are covered for certain indications, the file does not support that the enrollee met criteria for these services. Therefore, we decided that the Plan does not have to pay for the cardiovascular risk assessment panel provided on April 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chemotherapy administration (96401) provided on January 21, 2021.

You asked the Plan to pay for chemotherapy administration. You say that the billed drug is considered a chemotherapy agent. The Plan denied your request. The Plan says this was not billed correctly.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.

 In this case, the CPT Code Manual definition of code 96401 is chemotherapy administration, subcutaneous or intramuscular; non-hormonal anti-neoplastic. 

We find that CPT code 96401 is not supported in the medical record. Specifically, the records show that a chemotherapy drug was not administered. Based on this information, we decided that Medicare rules for coverage of chemotherapy administration have not been met. Therefore, we decided that the Plan does not have to pay for chemotherapy administration (96401) provided on January 21, 2021.
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 needs inpatient care. The Plan denied your request. The Plan says the enrollee is unstable for transfer and cannot tolerate 3 hours of intensive therapy.
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 physician reviewer found that the enrollee was admitted to the acute care hospital for weakness and bilateral lower extremity cellulitis. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for a intensive, multi-disciplinary rehabilitation program.
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: 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 you are receiving appropriate inpatient acute care and are currently unstable for transfer to an LTACH.
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 you are receiving acute hospital care, and acute care services have not been denied. The documentation does not support that you in this case requires services at the LTACH that are not available at the acute care hospital where you are currently receiving care. The requested LTACH services are not medically necessary, reasonable, and appropriate for your diagnosis and condition at this time. 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ground mileage (A0425) and non-emergency ambulance transports (A0428) provided on March 12, 2021.

You asked the Plan to pay for the ground mileage and non-emergency ambulance transports. The Plan denied your request. The Plan says ambulance transport to and from an outpatient office or facility is not a Medicare covered benefit.

Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. 

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 the ground mileage and non-emergency ambulance transports. Our reviewer says that the documentation does not support that the ambulance transports on March 12, 2021 were medically reasonable and necessary for the enrollee. Our physician reviewer found the review indicates that ambulance transport to and from an outpatient office or facility is not a Medicare covered benefit. Our reviewer found that the documentation does not support that other means of transport (such as stretcher van, wheelchair van, taxi, private car, or other type of vehicle) were contraindicated for this enrollee. Our physician reviewer also found that the documentation does not support that the enrollee needed the expertise, services and lifesaving and life-sustaining equipment that only a fully equipped ambulance can provide for safe transport on March 12, 2021.

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 ground mileage and non-emergency ambulance transports have not been met. Therefore, we decided that the Plan does not have to pay for the ground mileage (A0425) and non-emergency ambulance transports (A0428) provided on March 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the pneumatic compression device (E0675) and segmental
gradient pressure pneumatic appliance (E0673) provided February 25, 2020.
You asked the Plan to pay for pneumatic compression device and appliance. You say that please make this part
of the enrollee's covered services for safe and effective surgical procedures. The Plan denied your request. The
Plan says pneumatic compression devices are not covered by Medicare to prevent deep vein thrombosis during
and/or following surgery.
The Plan follows Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other than the facility or hospital for services furnished to the beneficiary while an inpatient. In this case, the enrollee used the equipment in the facility during and/or after surgery. Payment for this service would have been included under the facility claim. Payment for this service is the responsibility of the facility or hospital that provided the surgery. Therefore, we decided that the Plan does not have to pay for the pneumatic compression device (E0675) and segmental gradient pressure pneumatic appliance (E0673) provided February 25, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the endodontic therapies (D3330) provided on April 14, 2021.
You asked the Plan to pay for the endodontic therapies. You say that you believe these services should be covered. The Plan denied your request. The Plan says this service is not covered.
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 requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the endodontic therapies (D3330) provided on April 14, 2021.