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

We decided that the Plan does not have to pre-approve Dupixent pre-filled syringe.
You asked the Plan to pre-approve self-administered drug. You say that you are appealing with supporting
records. The Plan denied your request. The Plan says the denial of authorization for this drug is correct,
because this drug is not covered by Medicare Part B and the Plan does not administer the enrollee's Medicare
Part D prescription drug benefits.
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 Dupixent pre-filled syringe.
Benefits for self-administered 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: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approve inpatient psychiatric care from January 18, 2022, forward.
You asked the Plan to pre-approve inpatient psychiatric hospital services from January 18, 2022, forward. You
say that the services at issue are medically necessary. The Plan denied your request. The Plan says that the
services at issue are not medically necessary.
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 inpatient psychiatric hospital services
from January 18, 2022, forward. Our reviewer says that you do meet the criteria for acute inpatient mental
health treatment beyond the date in question of January 18, 2022, forward. Our physician reviewer found you
were aggressive and difficult to control. It did appear that active treatment was taking place beyond the date in
question. It did appear that the services for the dates in question were reasonably expected or medically
necessary to improve your 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 inpatient psychiatric hospital services from January 18, 2022, forward have
been met. Therefore, we decided that the Plan has to pre-approve inpatient psychiatric care from January 18,
2022, forward.
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: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gel-One.
You asked the Plan to pre-approve Gel-One. 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 Gel-One. Our reviewer says that the
requested drug is not medically reasonable and necessary. Our physician reviewer found the Plan requires a
trial of Orthovisc, Synvisc, or Synvisc One before they will approve the requested drug. In this case, there is no
evidence that the enrolle has tried and failed Orthovisc, Synvisc, or Synvisc-One. Furthermore, the
documentation does not support that Orthovisc, Synvisc, or Synvisc-One 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 Gel-One have not been met. Therefore, we decided that the Plan does not have
to pre-approve Gel-One.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for acute inpatient rehabilitation facility (IRF) admission and services.  You asked the Plan to pay for IRF care. You say that the enrollee can tolerate the intensity of services provided at an IRF, and this is the best option for her recovery. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. The enrollee's ongoing skilled therapy and nursing needs can be provided in a lower level of care.  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 pay for IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. 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.  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 pay for acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the ultrasound services coded 76700 provided on September 28, 2021.
You asked the Plan to pay for the ultrasound services. 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 separately payable.
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 76700 is a column II code to column I code 93976. 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 the ultrasound services coded 76700 provided on September 28, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ground mileage (CPT code A0425-SH) and ambulance
service, advanced life support, emergency transport, level 1 (CPT code A0427-SH) provided on March 26,
2021.
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your
request. The Plan says providers that render services or items to a prisoner or patient in a jurisdiction that meets
the conditions of 42 CFR 411.4(b) should indicate this fact on the claim by append a CPT code modifier QJ on
all lines with a line-item date of service during the incarceration period.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
CPT code A0427-SH, which exhibits modifier SH indicating, "Second concurrently administered infusion
therapy," and CPT code A0425-SH, which exhibits modifier SH indicating, "Second concurrently administered
infusion therapy," denied because the appropriate modifier was not appended to these codes indicating this
service was provided to a member who was incarcerated.
For patients who are incarcerated, modifier "QJ" should be appended to services to indicate the status of the
patient if incarcerated. There is a facility claim, for the same date of service, with a discharge status of 21,
indicating that the member was incarcerated. Services rendered to incarcerated members are not payable. 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 pay for ground mileage (CPT code A0425-SH) and ambulance
service, advanced life support, emergency transport, level 1 (CPT code A0427-SH) provided on March 26,
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group three power wheelchair with multiple power
options (K0862) and accessories (E1012, E2311, E1007, and E2359).
You asked the Plan to pre-approve a group three power wheelchair with multiple power options and
accessories. You say that this is medically necessary. The Plan denied your request. The Plan says the enrolle
can ambulate with a walker.
The Plan follows Medicare rules. Medicare rules say that a Group 3 power wheel chair with Multiple Power
Options (K0861, K0862, K0863, K0864) is covered only if the criteria listed in the rules section are met.
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 group three power wheelchair with
multiple power options and accessories. Our reviewer says that the requirements for coverage have not been
met. Our physician reviewer found the documentation does not reveal that the patient uses a ventilator attached
to a wheelchair or that she is at high risk for development of a pressure ulcer. Her Braden score was moderate
risk. The documentation is not consistent that the patient is unable to perform a functional weight shift. Her
upper extremity strength is 4/5, therefore her strength should be sufficient to perform independent pressure
relief. The physician documentation also states she has no incontinence and no problems urinating. The
physician documentation does not indicate objective evidence of spasticity on a physical exam that requires a
power seating system for management.
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 group three power wheelchair with multiple power options and accessories
have not been met. Therefore, we decided that the Plan does not have to pre-approve a group three power
wheelchair with multiple power options (K0862) and accessories (E1012, E2311, E1007, and E2359).
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Hyrdrocodone/APAP for the enrollee.  You asked the Plan to pre-approve this drug. You say that this is medically necessary for the enrollee. 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 Hyrdrocodone/APAP 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the cardiovascular risk screening (CPT code (s): 81404,
81405, 81406) provided to the enrollee on May 11, 2021.
You asked the Plan to pre-approve the testing. You say that the claim should be paid. The Plan denied your
request. The Plan says Medicare denies coverage for all cardiovascular risk screening assessment genomic
testing panels for suspected or documented cardiovascular disease.
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.
The test at issue in this appeal, the testing, is being requested solely for screening purposes. Medicare does not
cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pre-approve
the cardiovascular risk screening (CPT code (s): 81404, 81405, 81406) provided to the enrollee on May 11,
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 3 heavy duty power wheelchair (PWC) and
attachments for the enrollee.
You asked the Plan to pre-approve a Group 3 heavy duty PWC and attachments. You say that this is medically
necessary for the enrollee. The Plan denied your request. The Plan says that there is no documentation of the
enrollee's weight.
The Plan must follow Medicare rules. Medicare rules say that if a heavy duty PWC is provided and if the
beneficiary's weight is outside the range of 285 to 450 pounds, it will be denied as not reasonable and
necessary.
We looked at the file and Medicare rules. The file does not indicate that the enrollee's weight is within the
weight range. Based on this information, we decided that Medicare rules for coverage of a Group 3 heavy duty
PWC and attachments have not been met. Therefore, we decided that the Plan does not have to pre-approve a
Group 3 heavy duty power wheelchair (PWC) and attachments for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Atezolizumab (J9022) with Carboplatin (J9045) and Etoposide (J9181).  You asked the Plan to pre-approve Atezolizumab, Carboplatin, and Etoposide. You say that Atezolizumab, Carboplatin, and Etoposide are medically necessary. 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 may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use.   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 Atezolizumab, Carboplatin, and Etoposide. Our reviewer says that the requested chemotherapy treatment is not medically necessary. Our physician reviewer found the use of Atezolizumab for the enrollee's metastatic neuroendocrine (large cell) prostatic adenocarcinoma is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal.   We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Atezolizumab, Carboplatin, and Etoposide have not been met. Therefore, we decided that the Plan does not have to pre-approve Atezolizumab (J9022) with Carboplatin (J9045) and Etoposide (J9181).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a continuous glucose monitor and supplies to be rendered by the out-of-network (OON) provider.  You asked the Plan to pre-approve these items. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says there are in-network providers available to render the requested items.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.  The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items at issue in this appeal.  We found no exception that would require the Plan to pre-approve these items. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor and supplies to be rendered by the out-of-network (OON) provider.
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 admission to an LTACH is medically
necessary. The Plan denied your request. The Plan says the admission to an LTACH 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.
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 present setting 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.
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: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Accu-Chek test strips.  You asked the Plan to pre-approve Accu-Chek test strips. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the services are available from the preferred provider.  The Plan must follow Medicare rules. Medicare rules say that Plans may limit enrollees to preferred providers for durable medical equipment and supplies.  We looked at the file and Medicare rules. The requested services are not from the Plan's preferred provider. The Plan covers diabetic testing supplies from Contour and LifeScan OneTouch. The file shows that the Plan confirmed that the Plan's preferred Contour strips will work with your device. Therefore, we decided that the Plan does not have to pre-approve Accu-Chek test strips.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Feraheme for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your
request. The Plan says if the clinical criteria for this drug is met, the step therapy criteria must also be 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 the drug. Our reviewer says that the
requested drug is not medically reasonable or necessary. Our physician reviewer found the record indicates that
the enrollee has iron deficiency anemia. 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.
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 drug have not been met. Therefore, we decided that the Plan does not have
to pre-approve Feraheme for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Oxycodone for the enrollee.
You asked the Plan to pre-approve this drug. You say that this medication provides the patient significant relief
of pain. 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 Oxycodone 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a custom fabricated abutment (D6057) and an abutment supported crown (D6058) for tooth # 26.
You asked the Plan to pre-approve the dental services. You say that you were advised by a plan representative that you could appeal this. You say that you only used your cleaning benefits this year. You also say that you feel your benefit should be applied because you need these services. The Plan denied your request. The Plan says custom fabricated abutment is not listed as a covered service. The Plan also says that abutment supported crown is not listed as a covered service either.
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 custom fabricated abutment and abutment supported crown are not among those covered under this benefit.
Therefore, we decided that the Plan does not have to pre-approve a custom fabricated abutment (D6057) and an abutment supported crown (D6058) for tooth # 26.