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

We decided that the Plan does not have to pre-approve Epogen.
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.
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has anemia of chronic renal 
disease, not on dialysis. She has not tried and failed the Plan's required drugs, Retacrit or Procrit. The records 
do not show that the required drugs would be contraindicated or less effective; therefore, Epogen is 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 Epogen. 
Local Coverage Determination (LCD) L34633 referenced by the Plan is not valid for the state of Texas and 
was not used in the MAXIMUS determination
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says the enrollee has
exhausted the benefit.
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.
At the time the services were requested, the enrollee received 100 days of SNF care during the benefit period
from March 26, 2021, to December 2, 2021. The Plan has covered 100 days of SNF care. Although the enrollee
may still need skilled care, the Plan is not required to pay for more than 100 days of SNF coverage during this
benefit period. The enrollee will be eligible for a new benefit period when the enrollee has not been receiving
care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided that the Plan does
not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acupuncture treatment.
You asked the Plan to pre-approve acupuncture treatment. You say that you are appealing the denial for 
acupuncture for chronic migraine headaches. The doctor has been treating you for many years for lower back 
pain that may be associated with the migraines. The Plan denied your request. The Plan says based on the 
Medicare criteria, acupuncture is not a covered benefit for migraines.
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the 
Plan's rules apply in this case. 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the records show that acupuncture treatments are 
being requested for migraines. Acupuncture treatment is not covered for migraines. Therefore, we decided that 
the Plan does not have to pre-approve acupuncture treatment.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia (denosumab) (J0897).
You asked the Plan to pre-approve Prolia. You say that the requested drug is medically necessary. The Plan
denied your request. The Plan says the enrollee has not tried and failed the preferred drug, zoledronic acid.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain
Part B medications.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve Prolia. Our reviewer says that the step
therapy criteria have not been met. Our physician reviewer found the provided records do not indicate that the
enrollee has tried and failed the plan's preferred step one alternative, zoledronic acid. 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. Therefore, the reviewer found that the elements of the coverage criteria have not been met.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Prolia have not been met. Specifically, the file does not show that the enrollee
has tried and failed the preferred drug. Therefore, we decided that the Plan does not have to pre-approve Prolia
(denosumab) (J0897).
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 you would benefit from IRF care. The Plan denied
your request. The Plan says criteria for admission to the IRF setting have not been met. Your ongoing skilled
therapy and nursing needs can be provided at 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 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, multidisciplinary 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: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve SNF services.  

You asked the Plan to pre-approve SNF services. You say that a SNF admission is medically necessary. The Plan denied your request. The Plan says a SNF admission is not medically necessary.  

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 services. Our reviewer says that daily skilled services are not medically necessary. Our physician reviewer found that from a nursing perspective, the enrollee received oral medications. The enrollee had stable vital signs. She was treated for cellulitis with oral antibiotics. Regarding rehabilitation services, the enrollee received physical therapy (PT), speech therapy (ST) and occupational therapy (OT). The enrollee was independent for functional mobility including gait to 220 feet. The enrollee required varying assist with activities of daily living. She had cognitive impairment. There are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. As a practical matter, this enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.  

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Feraheme (Q0139).

You asked the Plan to pre-approve Feraheme. You say that Feraheme is medically necessary. The Plan denied your request. The Plan says a trial of Venofer or Infed is required before alternatives can be considered.

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 Feraheme. Our reviewer says that Feraheme is not medically necessary. Our physician reviewer found the record shows no trial of the plan preferred drugs or any reason they would be unsafe or ineffective 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 Feraheme have not been met. Therefore, we decided that the Plan does not have to pre-approve Feraheme (Q0139).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a visual field home monitoring device (0375T).

You asked the Plan to pre-approve a visual field home monitoring device. You say that the requested item is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met because the requested item is experimental/investigational.

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 visual field home monitoring device. Our reviewer says that the requested item is not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee has non-exudative macular degeneration. The record does not establish that the requested service is as effective as standard therapies for the enrollee's specific clinical 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 a visual field home monitoring device have not been met. Therefore, we decided that the Plan does not have to pre-approve a visual field home monitoring device (0375T).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an apicoectomy (D3410) and retrograde filling (D3430).  

You asked the Plan to pre-approve the apicoectomy and retrograde filling. You say that if you lose this tooth that has the bridge attached to it, you will lose the bridge. The Plan denied your request. The Plan says these services are not covered under your benefit package.  

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 pre-approve an apicoectomy (D3410) and retrograde filling (D3430).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a raised toilet seat.

You asked the Plan to pre-approve a raised toilet seat. You say that you have severe arthritis and find it painful to stand up from a seated position. The Plan denied your request. The Plan says this item is not a covered benefit.

The Plan covers all items that Medicare covers. Medicare rules state that raised toilet seats are not covered because they are not primarily medical in nature. 

While a raised toilet seat may be appropriate for C. Canlapan, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a raised toilet seat.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve custom fabricated abutments (D6057 x 4).

You asked the Plan to pre-approve dental services. You say that your insurance covers dental implants. You also say that these services should be covered. The Plan denied your request. The Plan says custom fabricated abutments are not listed as covered services.

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 abutments are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve custom fabricated abutments (D6057 x 4).
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the outpatient evaluation and management (EM) services provided on April 21, 2021, billed with code 99214.

You asked the Plan to pay for the EM services. You say that the services are payable for the reported diagnoses as this patient required a visit with a provider. The Plan denied your request. The Plan says that the claim was not billed with diagnosis codes for which medical nutrition therapy may be covered.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. 

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan has failed to substantiate its denial as the documentation does not support that the services at issue amount to medical nutrition therapy (MNT). As noted in the Medicare rules section, MNT is reported with a certain set of codes. The code billed for this encounter is not for MNT. While the records do support that the visit was provided to address the enrollee's need for weight loss, this does not constitute MNT as there was no assessment or evaluation by a registered dietician. Since no alternative denial rationale was offered by the Plan, we find that the denial is not supported. Therefore, we decided that the Plan has to pay for the outpatient evaluation and management (EM) services provided on April 21, 2021, billed with code 99214.

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: Unfavorable

We decided that the Plan does not have to pre-approve a custom fabricated abutment (D6057) and implant supported crown (D6066).

You asked the Plan to pre-approve the custom fabricated abutment and implant supported crown. You say that you would like to use the $930.00 you have accrued for the crown. 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 pre-approve a custom fabricated abutment (D6057) and implant supported crown (D6066).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor.  

You asked the Plan to pre-approve a therapeutic continuous glucose monitor. You say that this is medically necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met.  

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. Based on this information, we decided that Medicare rules for coverage of a therapeutic continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve admission to a SNF. You say that the requested admission to a SNF is medically necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet criteria.
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 admission to a SNF. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have any parental medication; complex wound care or nutrition given via a feeding tube. The enrollee is medically stable without any acute exacerbations of chronic medical problems. Her physical function is at or near her baseline and she can receive services at a lower level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of admission to a SNF have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a specialist office visit to be provided by an out-of-network (OON) provider.  

You asked the Plan to pre-approve a specialist office visit. You say that no eye specialist at the participating provider has been able to help him improve his vision. You also say that you would like to be evaluated by the requested eye specialist. The Plan denied your request. The Plan says this provider is an out-of-network provider, and there are available in-network providers in the patient's area that can provide this service.  

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/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a specialist office visit to be provided by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued stay at a skilled nursing facility (SNF).

You asked the Plan to pre-approve continued stay at a SNF. You say that the requested continued stay at SNF is medically necessary. The Plan denied your request. The Plan says the requested continued stay at SNF does not meet criteria.

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 continued stay at SNF. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee did not have any parental medications, complex wound care or nutrition given via a feeding tube. The enrollee received skilled care and improved; however, his functional improvement had plateaued by February 18, 2022 and he did not require any further inpatient skilled rehab services. The enrollee's function was at or near his prior level of function and he could be discharged to a lower level of care for further services. As of February 18, 2022, the enrollee required custodial services. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued stay at SNF have not been met. Therefore, we decided that the Plan does not have to pre-approve continued stay at a skilled nursing facility (SNF).