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

We decided that the Plan does not have to pre-approve Xiidra.
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 self-administered drugs are not covered.
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 Xiidra.
Benefits for these services 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex Interspinous Spacer device.
You asked the Plan to pre-approve the Vertiflex device. You say that you would like reconsideration because this procedure considered safe and and supported by clinical benefits to patients. The Plan denied your request. The Plan says the requested procedure is 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 the Vertiflex device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Food and Drug Administration states that the requested procedure is contraindicated in individuals with morbid obesiy defined as a body mass index of greater than 40. The record indicates that the enrollee has a body mass index of 41.6. 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 Vertiflex device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex Interspinous Spacer device
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your
request. The Plan says the enrollee can get the necessary rehabilitation, including physical and occupational
therapies, at the skilled nursing level of care with the goal of returning safely home.
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 the enrollee is medically stable with debility. With her comorbid conditions
being stable, she does not need physician supervision 3 times per week (at a minimum) for the ongoing
management of any active or acute exacerbation of chronic medical conditions. There are no acute or complex
rehab nursing needs noted in the record. The enrollee does not need intensive therapies, consisting of at least 3
hours of therapy per day at least 5 days per week with multidisciplinary approach to daily therapy. IRF
admission is not medically necessary based on lack of medical complexity, and rehab nursing needs and current
functional status. While the enrollee may benefit from physical and occupational therapy, needs can be safely
met in an alternate and lower intensity setting such as in a skilled nursing facility or in home with therapies.
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of stabilization device (22869).
You asked the Plan to pre-approve the insertion of stabilization device (22869). You say that the member has
failed several months of conservative approaches to treatment. You say that this treatment is considered safe
and effective, and the necessary coverage should be provided. The Plan denied your request. The Plan says this
procedure can only be considered if you are in a clinical trial.
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 insertion of stabilization device
(22869). Our reviewer says that the requested items/services are not considered medically reasonable and
necessary in this case. Our physician reviewer found that interlaminar distraction devices remain experimental.
More research is needed to show safety and efficacy.
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 insertion of stabilization device (22869) have not been met. Therefore, we
decided that the Plan does not have to pre-approve the insertion of stabilization device (22869).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the office visit to be provided by an out-of-network
(OON) provider.
You asked the Plan to pre-approve the office visit. You say that you are currently post-operative, and you need
to continue care with this provider. The Plan denied your request. The Plan says the provider is out-of-network.
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 provider at issue in this case is not a network provider with the Plan. 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 office visit. Our reviewer says that the service is not medically
necessary. Our physician reviewer found there is no continuity of care issue because you are receiving routine
care for a chronic non-pressure ulcer. 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 office visit have not been met.
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 the office visit. Therefore, we decided that the Plan
does not have to pre-approve the office visit to be provided by an out-of-network (OON) provider.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Trelstar (J3315) and administration (96372).
You asked the Plan to pre-approve Trelstar and administration. You say that the drug is medically necessary.
The Plan denied your request. The Plan says you have not tried the preferred drug.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain
Part B medications.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve Trelstar and administration. Our
reviewer says that the service is not medically necessary. Our physician reviewer found you have not tried and
failed the required drugs and the documentation does not support that the preferred drug would likely be less
effective, and/or would likely have adverse effects for you.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Trelstar and administration have not been met. Therefore, we decided that the
Plan does not have to pre-approve Trelstar (J3315) and administration (96372).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group three power wheelchair and power seat options.

You asked the Plan to pre-approve a group three power wheelchair. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested device.

The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for enrollees who have a mobility limitation that is due to: 

1. A neurological condition; 
2. Myopathy; or 
3. Congenital skeletal deformity.

The file does not show that the enrollee has a mobility limitation that is due to a neurological condition, myopathy or congenital skeletal deformity. Therefore, we decided that the Plan does not have to pre-approve a group three power wheelchair and power seat options.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the imfinzi, dexamethasone, ondansetron, cisplatin
powder, and gemcitabine.
You asked the Plan to pre-approve the imfinzi, dexamethasone, ondansetron, cisplatin powder, and
gemcitabine. You say that the drugs are medically necessary. The Plan denied your request. The Plan says the
drugs are not medically necessary.
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 the imfinzi, dexamethasone,
ondansetron, cisplatin powder, and gemcitabine. Our reviewer says that the service is not medically necessary.
Our physician reviewer found the drugs are not FDA approved for the enrollee's diagnosis and their use is not
supported by any of the major drug compendia.
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 imfinzi, dexamethasone, ondansetron, cisplatin powder, and gemcitabine
have not been met. Therefore, we decided that the Plan does not have to pre-approve the imfinzi,
dexamethasone, ondansetron, cisplatin powder, and gemcitabine.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve amivantamab-vmjw (J9061).
You asked the Plan to pre-approve amivantamab-vmjw. You say that the drug is medically necessary. The Plan
denied your request. The Plan says the drug is not medically necessary.
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 amivantamab-vmjw. Our reviewer says
that the service is not medically necessary. Our physician reviewer found this drug is not FDA approved for
this member's diagnosis and is not supported by any of the compendia.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of amivantamab-vmjw have not been met. Therefore, we decided that the Plan
does not have to pre-approve amivantamab-vmjw (J9061).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve surgical placement of mini implants (D6013) and
custom fabricated abutments (D6057).
You asked the Plan to pre-approve the dental services. You say that these services are medically necessary. The
Plan denied your request. The Plan says these services are not covered by the Plan's dental benefit.
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
surgical placement of mini implants (D6013) and custom fabricated abutments (D6057).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically
necessary. The Plan denied your request. The Plan says the requested admission to an IRF is 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 considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found there is no need for physician supervision 3 times per week (at a minimum) for the
ongoing management of any active or acute exacerbations of chronic medical conditions. Based upon the
current level of function, you do not require an intensive, complex, multidisciplinary approach to daily therapy.
Documentation does not support the need for a therapy program consisting of at least 3 hours of therapy per
day at least 5 days per week with an interdisciplinary approach to rehabilitation care. There are no documented
acute rehabilitation nursing needs. While you may benefit from physical therapy and occupational therapy, the
rehabilitation needs can be safely met in an alternate and lower intensity 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 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an extra battery for portable oxygen concentrator
(E1356).
You asked the Plan to pre-approve an extra battery for portable oxygen concentrator. You say that the new
machine batteries only lasts 3 hours and you cannot go anywhere. You are on oxygen 24/7 and it is medically
necessary to have one. The Plan denied your request. The Plan says this request is for convenience rather than
medical necessity.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose.
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we
decided that the Plan does not have to pre-approve an extra battery for portable oxygen concentrator (E1356).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve extraction (D7210 and D7230), and an alveoloplasty (D7310) provided by a participating provider.

You asked the Plan to pre-approve extraction and an alveoloplasty. You say that you would like approval to provide these services. The Plan denied your request. The Plan says the requested dental services are not 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 items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve extraction (D7210 and D7230), and an alveoloplasty (D7310) provided by a participating provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a grab bar.
You asked the Plan to pre-approve a grab bar. You say that you have vertigo and need the support, so you do
not lose your balance and fall. 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 grab bars are not covered because
they are not primarily medical in nature.
While a grab bar may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item.
Therefore, we decided that the Plan does not have to pre-approve a grab bar.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa.

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. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has chronic bilateral knee pain due to bilateral primary osteoarthritis/patellofemoral osteoarthritis. He has not had a trial and failure of physical therapy or a home exercise program. The Euflexxa is not reasonable or medically necessary at this time. 

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 Euflexxa.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the office visit to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve the office visit. You say that the enrollee does not have a specialty provider for neurosurgery within the network 30 miles from their residency. The Plan denied your request. The Plan says the provider is out-of-network.

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. The record shows an in-network provider located 5.21 miles of the enrollee's residence. Therefore, we decided that the Plan does not have to pre-approve the office visit to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lumbar fusion procedure.
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says there is no clear indication given for the procedure effectiveness when compared to risk.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the requested services. Our physician reviewer found that the requested services are not indicated for the enrollee's condition. There is no documented instability at L-4-5. The requested services are not medically reasonable or necessary at this time. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve a lumbar fusion procedure
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve home oxygen services.
You asked the Plan to pre-approve the requested services. You say that a walking test shows the medical need
for oxygen. The Plan denied your request. The Plan says that the enrollee does not meet criteria.
The Plan must follow Medicare rules. The rules say that for patients with arterial PO2 at or above 60 mm Hg or
arterial O2 saturation at or above 90%, there is a rebuttable presumption of non-coverage for home oxygen.
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's oximetry testing on December 29, 2021, meets Medicare criteria for oxygen
need. The enrollee's oxygen saturation (SpO2) was 87% walking on RA, corrects to 92% with oxygen (O2)
supplementation. The documentation supports that home oxygen, with stationary concentrator and portable
oxygen, is 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 the requested services have been met. Therefore, we decided that the Plan has to
pre-approve home oxygen services.
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.