Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) supply allowance (K0553).  You asked the Plan to pre-approve a CGM supply allowance. You say that the items are medically necessary. The Plan denied your request. The Plan says the member does not use insulin with at least three daily injections nor do they require frequent self-adjustment of insulin dosage based on the blood glucose testing results.  The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan.  We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of a CGM supply allowance have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) supply allowance (K0553).
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Factor V Leiden (FVL) testing.  You asked the Plan to pre-approve F5 testing. You say that this is medically necessary. The Plan denied your request. The Plan says this test is not covered by Medicare outside of pregnant patients.  The Plan must follow Medicare rules. Medicare rules say that Factor V Leiden testing is non-covered except for pregnant patients.   We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of F5 testing have not been met. Therefore, we decided that the Plan does not have to pre-approve Factor V Leiden (FVL) testing.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a knee arthroscopy.  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 efficacy of knee arthroscopy for patellofemoral degenerative joint disease has not been established. The use is considered experimental in nature, as positive outcomes have not been shown. 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 knee arthroscopy.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing visits (G0299 x 2).
You asked the Plan to pre-approve skilled nursing visits. You say that the enrollee needs these services. The
Plan denied your request. The Plan says the requested home health visits are not medically necessary.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for
home health care services.
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 skilled nursing visits. Our reviewer says
that the requested home health visits are not medically necessary. Our physician reviewer found the
documentation does not support that the enrollee requires skilled nursing services to provide treatment that is
medically necessary. The reviewer found that the enrollee does not require skilled nursing services to
effectively provide treatment, care, and/or services in order to improve the enrollee's condition, perform a
maintenance program to maintain the enrollee's condition and/or prevent deterioration. The reviewer found that
the enrollee has been medically stable without any recent exacerbations of chronic medical problems or
hospitalizations. Therefore, the reviewer found that the requested home health visits are not 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 skilled nursing visits have not been met. Specifically, the file does not show that
the enrollee requires skilled nursing services to effectively provide treatment, care, and/or services in order to
improve the enrollee's condition, perform a maintenance program to maintain the enrollee's condition and/or
prevent deterioration. Therefore, we decided that the Plan does not have to pre-approve skilled nursing visits
(G0299 x 2).
Appeal type: Step-Therapy
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Prolia 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 this is not medically necessary.  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 case file does not contain documentation of trial and failure of Zoledronic acid. The documentation does not support that Zoledronic acid 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 drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve compression stockings identified with code A6549.  You asked the Plan to pre-approve the compression stockings. You say that you need these items. The Plan denied your request. The Plan says these are not covered items.  The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are noncovered because they do not meet the statutory definition of a surgical dressing.   Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6549.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a replacement prosthetic leg.  You asked the Plan to pre-approve the prosthetic. You say that this is medically necessary. The Plan denied your request. The Plan says a request for K3 knee does not meet Medicare criteria as reasonable and necessary.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the prosthetic. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the medical notes from the enrollee's treating providers document need for a wheelchair and/or walker for mobility. Records do not consistently support that the enrollee is a K3 ambulator to meet criteria for the requested 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 the prosthetic have not been met. Therefore, we decided that the Plan does not have to pre-approve a replacement prosthetic leg.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an Orthofix Trinity Elite allograft.  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 requested Orthofix Trinity Elite allograft is considered experimental in nature for spinal surgery. More research is needed to show its 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 an Orthofix Trinity Elite allograft.
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 3 hours of daily physical therapy are appropriate, and you have the strength and willpower to do it. The Plan denied your request. The Plan says you do not meet the Medicare criteria for admission to an IRF.  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 that the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical problems are stable. There are no complex nursing or rehabilitation needs. 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 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: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve 1 skilled nursing visit (G0299) every 9 weeks, and 14 hours of home health aide services (G0156) every week.  You asked the Plan to pre-approve the home health services. You say that the services are necessary. The Plan denied your request. The Plan says the requested home health services are not medically necessary.  The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.  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 home health services. Our reviewer says that the home health services are not medically necessary. Our physician reviewer found the provided documentation does not indicate that skilled home health nursing services are required to effectively provide treatment, care, and/or services in order to improve your condition, or to establish/perform a maintenance program to maintain your condition and/or prevent deterioration. The documentation shows that you are independent with your activities of daily living with set-up assistance, and you have family available in the evening to assist with your care. Therefore, the reviewer found that the skilled home health services are not medically necessary and therefore the associated home health aide services are not medically necessary either.  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 home health services have not been met. Specifically, the file does not indicate that skilled home health nursing services are required to effectively provide treatment, care, and/or services in order to improve your condition, or to establish/perform a maintenance program to maintain your condition and/or prevent deterioration. Therefore, we decided that the Plan does not have to pre-approve 1 skilled nursing visit (G0299) every 9 weeks, and 14 hours of home health aide services (G0156) every week.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a total knee arthroplasty (TKA).  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 unilateral primary osteoarthritis of the right knee. He has pain with weight bearing and rotational activities. X-rays from February 17, 2022 are noted to show bone-on-bone apposition throughout the medial compartment with erosion of the posterior medial plateau and varus deformity. There is no documentation of a trial of recent, reasonable, and comprehensive less invasive conservative care measures. He had a cortisone injection on February 5, 2021 that did not provide much relief and the next exam on December 28, 2021 had a 10 month gap between exams. It is not clear if additional treatment was trialed during this period. Trial and failure of any formal physical therapy or viscosupplementation injections is not evident based on the documentation. The TKA is 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 total knee arthroplasty (TKA).
Appeal type: Practitioner Services
Decision: Favorable

 We decided that the Plan has to pre-approve photochemotherapy for the enrollee.  You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says that the request is not approved at this time.  The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 the services. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found Narrowband UVB Phototherapy is the standard of care for Cutaneous T-cell Lymphoma, which a life-threatening disease.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pre-approve photochemotherapy for the enrollee.   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 the continuous positive airway pressure (CPAP) device (E0601) and humidifier (E0562).  You asked the Plan to pre-approve the CPAP device and humidifier. You say that the items are medically necessary. The Plan denied your request. The Plan says the documentation submitted did not indicate that the enrollee had a face-to-face clinical re-evaluation by the physician, that the symptoms improved with CPAP use, and documented that the device was used 21 out of 30 consecutive nights for more than 4 hours each night.  The Plan must follow Medicare rules. Medicare rules say that adherence to therapy is defined as use of PAP greater than or equal to 4 hours per night on 70% of nights during a consecutive thirty (30) day period anytime during the first three (3) months of initial usage.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the CPAP device and humidifier have not been met. Therefore, we decided that the Plan does not have to pre-approve the continuous positive airway pressure (CPAP) device (E0601) and humidifier (E0562).
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve home health services.  You asked the Plan to pre-approve the requested services. You say that the enrollee requires bladder injections. The Plan denied your request. The Plan says the enrollee does not meet the qualifying criteria.   The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.  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 enrollee was discharged from home health skilled nursing and therapy services. As no skilled nursing or therapy services are being provided, home health aides services are not covered by Medicare.  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 home health services.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Invokana 100mg tablets.  You asked the Plan to pre-approve Invokana 100mg tablets. You say that the enrollee has been stable on this medication for more than 4 years. You also say that changing the medication at the enrollee's current age could have negative side effects on her health. The Plan denied your request. The Plan says the enrollee's Medicare plan does not cover outpatient prescription drugs.  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 Invokana 100mg tablets.   Benefits for Invokana 100mg tablets 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: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the Volara system 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 is no data to support the effectiveness of this device.  The Plan must follow Medicare rules. Medicare rules say the HFCWODs are covered only when they are medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases.   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 device is not medically reasonable or necessary. Our physician reviewer found the Volara system is not medically necessary.  This system combines intra-airway oscillations for clearance, positive pressure for lung expansion, and nebulization of medications.   There is insufficient evidence that this device is effective in the treatment of chronic obstructive pulmonary disease, or in clearance of secretions.  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 the Volara system for the enrollee.