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

We decided that the Plan does not have to pre-approve skilled nursing facility services.
You asked the Plan to pre-approve skilled nursing facility services. You say that skilled nursing facility services are medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met.
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 skilled nursing facility services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment in a skilled nursing facility beyond the last covered date. The documentation does not reveal evidence of ongoing complex wound care, new enteral feedings, or other skilled nursing need. Your functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment beyond the last covered date. You do not require skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis" in a facility beyond the last covered date. 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 facility services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility services.
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 disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
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 medically necessary. Our physician reviewer found the enrollee was admitted to the hospital on January 28, 2022 with pneumonia.
The physical therapy note dated February 2, 2022 states he needs minimal assist to sit up and walking 40 feet with a two wheeled walker and moderate assist to stand up. He does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require 15 hours per week of rehabilitative services and regular physician evaluation. 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: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve coverage for GelSyn-3.
You asked the Plan to pre-approve GelSyn-3. You say that GelSyn-3 is medically necessary. The Plan denied
your request. The Plan says the enrollee has not tried any of the preferred agents.
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 GelSyn-3. Our reviewer says that
GelSyn-3 is not medically necessary at this time. Our physician reviewer found the enrollee has not trialed a
viscosupplemental treatment such as Orthovisc, Synvisc, or Synvisc-One. Step therapy, as outlined by the Plan,
requires that one of these be trialed first. The documentation does not outline contraindications or reasons that
one of the preferred medications was not considered or that the plan's additional required drug would likely be
less effective and/or likely have adverse effects for the enrollee. Without the support of the documentation, step
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 GelSyn-3 have not been met. Therefore, we decided that the Plan does not have
to pre-approve coverage for GelSyn-3.
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 LTACH care is medically necessary for
the enrollee's condition. The Plan denied your request. The Plan says rules for LTACH care have not been met.
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 indicating medical necessity for 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 acute care hospital 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. The requested LTACH services are not medically necessary,
reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and
effectively only on an inpatient basis.
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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.
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 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 these services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee presented to the emergency room on December 21, 2021 with weakness that started give weeks prior after a toe amputation. He had recent decrease in strength and increased frequency of falls. By February 10, 2022 he is noted to be off supplemental oxygen and is on oral Lasix. His delirium resolved and he has been treated with physical therapy for six weeks in the hospital. He has no skilled nursing needs. He has skilled therapy needs but does not require skilled therapy on a daily basis. As a practical matter, the enrollee does not require the necessary services on an inpatient basis at the SNF 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluations (D0120), bitewing x-rays (D0274), and prophylaxes (D1110) provided on January 17, 2019, and July 25, 2019.
You asked the Plan to pay for the periodic oral evaluations, bitewing x-rays, and prophylaxes. You say that the treating provider is in-network, and the provider was supposed to file these claims. You also say that you were not aware these claims were not filed in a timely manner. The Plan denied your request. The Plan says these claims were received on October 1, 2021 which is past the allowed 12-month timeframe.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. The record shows that a claim for the periodic oral evaluations, bitewing x-rays, and prophylaxes was not filed until October 1, 2021. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluations (D0120), bitewing x-rays (D0274), and prophylaxes (D1110) provided on January 17, 2019, and July 25, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the LTACH services are medically
necessary. The Plan denied your request. The Plan says the enrollee does not meet Medicare criteria for
coverage of the LTACH services.
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 are no services at the LTACH that the patient requires that are not already
available and covered at the current facility. Transfer to LTACH is not medically necessary as it would not be
clinically advantageous.
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 long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve three bone replacement grafts for ridge preservation (D7953 x3) and alveoloplasties in conjunction with extractions (D7310) of the upper right, upper left, lower right, and lower left quadrants.
You asked the Plan to pre-approve the bone replacement grafts and alveoloplasties. You say that you got the letter saying all of your teeth would be pulled. You also say that you need to get false teeth because you keep losing teeth and you need full dentures paid for. The Plan denied your request. The Plan says bone replacement graft is not a covered service under your benefit plan. The Plan also says that alveoloplasty is not reimbursed as a separate procedure when surgical extractions are performed.
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. The Plan covers alveoloplasties when the services are medically necessary and reasonable. 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 alveoloplasties. Our reviewer says that alveoloplasty (D7310) does not meet the criteria for coverage since the surgical extractions also involves the shaping of the alveolar bone. Our physician reviewer found an alveoloplasty is the reshaping of the alveolar bone by removing bony spicules, bulbous areas and undercuts to accommodate the seating of a dental prosthesis. Surgical extractions (D7210) involve extractions requiring the removal of bone along with smoothing bone and removing spicules to allow uneventful healing. Our reviewer also found that being that this is being done in the course of surgical extractions in this case, there is no need for a separate alveoloplasty procedure since the same thing is accomplished during the surgical procedure. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the alveoloplasties have not been met. Bone replacement graft for ridge preservation (D7953) is not a covered dental service. Therefore, we decided that the Plan does not have to pre-approve three bone replacement grafts for ridge preservation (D7953 x3) and alveoloplasties in conjunction with extractions (D7310) of the upper right, upper left, lower right, and lower left quadrants.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Evenity (J3111).
You asked the Plan to pre-approve Evenity. You say that Evenity is medically necessary. The Plan denied your
request. The Plan says a trial of Forteo is required before Evenity 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 Evenity. Our reviewer says that Evenity
is not medically necessary. Our physician reviewer found the record shows no trial of the plan preferred drug or
any reason it would be unsafe or ineffective.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Evenity have not been met. Therefore, we decided that the Plan does not have to
pre-approve Evenity (J3111).
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ilumya.
You asked the Plan to pre-approve Ilumya. You say that Ilumya is medically necessary. The Plan denied your request. The Plan says the member has not tried and failed the preferred step therapy drug(s): Remicade, Inflectra or Infliximab, and Stelara.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Ilumya. Our reviewer says that Ilumya is not medically necessary at this time. Our physician reviewer found the documentation does not support that Remicade, Inflectra or Infliximab and Stelara 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 Ilumya have not been met. Therefore, we decided that the Plan does not have to pre-approve Ilumya.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa.
You asked the Plan to pre-approve Euflexxa. You say that Euflexxa is medically necessary. The Plan denied
your request. The Plan says you must try and fail Orthovisc, Monovisc, and Synvisc first.
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 Euflexxa. Our reviewer says that step therapy criteria
are not met. Our physician reviewer found the documentation does not support that Orthovisc, Monovisc, and
Synvisc would likely be less effective, and/or would likely have adverse effects for you 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 Euflexxa have not been met. Therefore, we decided that the Plan does not have
to pre-approve Euflexxa.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the MTHFR genetic testing rendered on August 10, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that MTHFR testing is not covered.
We looked at the file and Medicare rules. The testing at issue is MTHFR testing. Therefore, we decided that the
Plan does not have to pay for the MTHFR genetic testing rendered on August 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99214), laboratory services (80061, 83036), routine venipuncture (36415), influenza virus vaccine (90686), and the administration of the influenza vaccine (G0008) rendered by the out-of-network (OON) provider on October 8, 2021.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the item/services were rendered by an out of network provider, without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the item/services at issue in this appeal. The Plan did not pre-approve the item/services at issue. We found no exception that would require the Plan to pay for the item/services. Therefore, we decided that the Plan does not have to pay for the office visit (99214), laboratory services (80061, 83036), routine venipuncture (36415), influenza virus vaccine (90686), and the administration of the influenza vaccine (G0008) rendered by the out-of-network (OON) provider on October 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the filling (D2392) for tooth # 13 provided on November 11,
2021.
You asked the Plan to pay for the dental service. You say that this was an emergency service after your
temporary filling had broken off. You say that if it was not for the second temporary filling, you would have
lost the tooth. You also say that this service should be covered. The Plan denied your request. The Plan says
fillings are covered once every 12 months for the same tooth/surface. The Plan also says that this benefit has
been exhausted.
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 and fillings are listed as covered, the
frequency limit for this benefit has been exhausted.
The record shows that the Plan paid for a filling for tooth # 13 that you received on August 2, 2021.
Therefore, we decided that the Plan does not have to pay for the filling (D2392) for tooth # 13 provided on
November 11, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda for the enrollee.
You asked the Plan to pre-approve Keytruda. You say that Keytruda is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not 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 Keytruda. Our reviewer says that Medicare coverage criteria are not met. Our physician reviewer found it is unclear what prior therapy the enrollee has received. This request for Keytruda is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. Medicare coverage criteria are not 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 Keytruda have not been met. Therefore, we decided that the Plan does not have to pre-approve Keytruda for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), prophylaxis (D1110), preventive procedures (D1999), and resin-based composite (D2332) provided on October 18, 2021, and November 1, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the periodic oral evaluation, prophylaxis, preventive procedures, and resin-based composite. You say that you believe these services should be covered. You also say that all of the bills prior to this one have been covered under the Plan, and no one told you that this provider was no longer in-network. The Plan denied your request. The Plan says the treating provider is considered OON with your 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 covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation (D0120), prophylaxis (D1110), preventive procedures (D1999), and resin-based composite (D2332) provided on October 18, 2021, and November 1, 2021 by an out-of-network (OON) provider.