Persius/hicric huggingface dataset:
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Eylea (J0178).
You asked the Plan to pre-approve Eylea. The Plan denied your request. The Plan says this request does not meet the the Plan's Part B step therapy criteria for the requested drug. 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 Eylea. Our reviewer says that Eylea is not medically reasonable and necessary for the enrollee. Our physician reviewer found the Plan requires a trial of drug Avastin/Bevacizumab before they will approve the requested drug. Our reviewer also found that there is no documentation provided indicating that the Plan's required drug(s) would likely be less effective and/or likely have adverse effects for the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Eylea have not been met. Therefore, we decided that the Plan does not have to pre-approve Eylea (J0178).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a spine cage and allograft.
You asked the Plan to pre-approve the requested services. You say that your pain in sever. The Plan denied
your request. The Plan says the services in the setting of spine fusion has not been demonstrated in the peerreviewed literature.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
The file shows that a Blackhawk cervical spine cage and an allograft bone substitute 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 the requested services. Our physician reviewer
found that the spinal cage combined with the requested allograft is experimental in cervical spine surgery.
More research is needed to show safety and efficacy. Therefore, the requested services are not considered
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 the requested services have not been met. Therefore, we decided that the Plan
does not have to pre-approve a spine cage and allograft
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing provided on August 21, 2020, billed with codes 80157, 80177, 80201, 80162, 80159, and 80173.
You asked the Plan to pay for the drug testing as billed. You say that the billed services should be paid. The Plan denied your request. The Plan says the denied codes are for blood testing, and no blood sample was taken based on the documentation
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. The codes at issue in this case are not supported. Specifically, these codes refer to testing on blood samples.
The records clearly show that a urine sample was submitted. Based on this information, we decided that Medicare rules for coverage of the drug testing as billed have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing provided on August 21, 2020, billed with codes 80157, 80177, 80201, 80162, 80159, and 80173
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that you are still very weak and are not comfortable
enough to be released to go home. You say that you are unable to receive the care at home because you live
independently and are not able to walk. The Plan denied your request. The Plan says the records do not show
you have skilled nursing or therapy needs that need to be provided on a daily basis as an inpatient only status.
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 care. Our reviewer says that daily
skilled nursing services are not necessary. Our physician reviewer found that the records are not clear on your
functional decline to clarify if daily skilled therapy services are needed.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve SNF care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device for the enrollee.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your
request. The Plan says there has not been a failure of a reasonable trial of a basic pump.
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 device. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found the provided records do not document that the enrollee has had an adequate trial of a standard pump to
say that there are unique characteristics that would indicate the segmented pump over a standard pump.
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 device have not been met. Therefore, we decided that the Plan does not have
to pre-approve a pneumatic compression device for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for to pay for procedure code 93976 billed for date of service 
October 6, 2021.
You asked the Plan to pay for procedure code 93976. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says this code is a bundled code.
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, we have confirmed that code 93976 
is a column II code to column I code 76856. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for to pay for procedure code 93976 billed for date of service 
October 6, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve twenty (20) additional routine transportation trips (A0120).
You asked the Plan to pre-approve additional routine transportation trips. You say that you are in a wheelchair and you have a broken femur with arthritis and high blood pressure. You also say that you are limited to movement and have issues with your arthritis which has caused you to wear a surgical boot on your foot. The Plan denied your request. The Plan says additional trips would exceed your benefit limit.
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. The records show that you have used twelve (12) one-way transportation trips out of the allowed twenty-four (24) one-way trips approved. Once 24 trips are used, the benefit will be exhausted. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to pre-approve twenty (20) additional routine transportation trips (A0120).
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Remicade.
You asked the Plan to pre-approve Remicade. You say that the requested Remicade is medically necessary. The Plan denied your request. The Plan says that the requested Remicade is not medically necessary.
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 Remicade. Our reviewer says that the requested Remicade is medically necessary. Our physician reviewer found the record indicates that the enrollee has a diagnosis of rheumatoid arthritis. The Medicare approved drug compendia contain a supportive citation for the use of the requested drug in the enrollee's clinical situation. Dose requested, absent a prohibition in the compendia of such use, is not a controlling factor in determining whether a drug is prescribed for a medically accepted indication. The elements of the coverage criteria are satisfied. 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 Remicade have been met. Therefore, we decided that the Plan has to pre-approve Remicade.
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: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve simple extractions (D7140), surgical extractions (D7210), and deep sedation/general anesthesia (D9222 and D9223 x3).
You asked the Plan to pre-approve the extractions and deep sedation/general anesthesia. You say that you desperately need the extractions provided. The Plan denied your request. The Plan says that these services are not billable after dentures. The Plan also says that anesthetic services are only covered when the associated services are approved.
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. We looked at the file and Medicare rules. The record shows that you received a maxillary immediate denture (D5130) on October 18, 2021 which is why the Plan denied the services at appeal. However, immediate dentures can be fabricated prior to extractions in order for them to be completed for use right after the extractions are done. The fact that an immediate denture was reimbursed does not preclude payment for extractions. We requested x-rays from the Plan but received no direct evidence that the teeth that were requested to be extracted are already gone. Based on this information, we decided that the Plan's rules for coverage of the extractions and deep sedation/general anesthesia have been met. Therefore, we decided that the Plan has to pre-approve simple extractions (D7140), surgical extractions (D7210), and deep sedation/general anesthesia (D9222 and D9223 x3).
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 an epidural steroid injection.
You asked the Plan to pre-approve an epidural steroid injection. You say that the requested epidural steroid injection is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested epidural steroid injection.
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 epidural steroid injection. Our reviewer says that the enrollee does not meet criteria for the requested epidural steroid injection. Our physician reviewer found there is no documentation that pain relief from the prior epidural steroid injection lasted for at least three months. There is no documented provider evaluation at this time. There is no evidence that the member is attending physical therapy or in an active home exercise program. The review has determined that the enrollee does not meet the above LCD criteria for the requested epidural steroid injection. 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 epidural steroid injection have not been met. Therefore, we decided that the Plan does not have to pre-approve an epidural steroid injection.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an interspinous stabilization device.
You asked the Plan to pre-approve the requested services. You say that the enrollee's condition has limited his
activities of daily living. The Plan denied your request. The Plan says the device is contraindicated for spinal
disease that would prevent implantation.
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 requested services. Our physician
reviewer found that interspinous stabilization devices remain experimental for spine surgery usage. More
research is needed to show its safety and efficacy. Therefore, the requested services are 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 the requested services have not been met. Therefore, we decided that the Plan
does not have to pre-approve an interspinous stabilization device.
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria.
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 you do not require treatment by multiple therapies, including either physical therapy 
or occupational therapy, and an intensive rehabilitation therapy program. There is not a reasonable expectation 
that you 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Linzess for the enrollee.
You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your request. The Plan says that this is not covered under Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Linzess 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional non-emergent routine transportation trips 
(A0120).
You asked the Plan to pre-approve additional routine transportation trips. You say that you are being treated for 
cancer. You need additional transportation for your treatment. The Plan denied your request. The Plan says 
additional trips would exceed your benefit limit.
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 36 one-way trips per year. 
We looked at your request, the records in the case file, and the rules. The records show that you have used 
sixteen (16) one-way transportation trips out of the allowed thirty-six (36) one-way trips approved. Once 36 
trips are used, the benefit will be exhausted. Based on this information, we decided that the Plan's rules for 
coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to pre approve additional non-emergent routine transportation trips (A0120).
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 the requested orthotics are medically necessary. 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.    The 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.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Retacrit.
You asked the Plan to pre-approve Retacrit. The Plan denied your request. The Plan says costs associated with
a clinical trial are the responsibility of Original Medicare.
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of
qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as
people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in
Original Medicare and the plan cost-sharing for the same services.
In this case, you asked the Plan to pre-approve Retacrit as part of a clinical trial. The Plan does not cover
routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have to preapprove Retacrit.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the hospital doesn't have the ability to get your leg strength back where it previously was. You say that you just need a little bit of help to get your independence back. The Plan denied your request. The Plan says that you do not require complex daily nursing care that must be provided in a skilled nursing facility.
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 care. Our reviewer says that the enrollee qualifies for SNF coverage. Our physician reviewer found that you are functioning below your baseline and have documented skilled therapy needs. Daily skilled services are required to establish a maintenance program and/or to prevent deterioration of your condition. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have been met. The Plan must continue coverage for the SNF skilled service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve SNF care.
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: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve side guards, privacy flaps and a transit system.  You asked the Plan to pre-approve the requested wheelchair and accessories. You say that the requested wheelchair and accessories are medically necessary. The Plan denied your request. The Plan says while the wheelchair and Medicare allowed accessories are approved, the side guards, privacy flaps and a transit system are not covered by Medicare or the Plan.  The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The rules say equipment must be appropriate for use in the home. Side guards, privacy flaps and a transit system do not service a medical purpose and are not required to use in the home. Therefore, we decided that the Plan does not have to pre-approve side guards, privacy flaps and a transit system.