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

We decided that the Plan does not have to pre-approve Ilumya, 100 mg/ml syringe.
You asked the Plan to pre-approve Ilumya. You say that the requested drug is medically necessary. The Plan denied your request. The Plan says the enrollee has not tried and failed at least 2 of the preferred drugs, Cimzia, Enbrel, Entyvio, Humira, Renflexis, Skyrizi, or Cosentyx.
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 the requested drug, Ilumya, is not medically necessary. Our physician reviewer found the provided documentation does not indicate that the enrollee has tried at least 2 of the preferred drugs. The reviewer also found that 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 requested drug is not medically necessary as the step therapy criteria has 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 Ilumya have not been met. Specifically, the file shows that the enrollee has not tried and failed at least 2 of the preferred drugs. Therefore, we decided that the Plan does not have to pre-approve Ilumya, 100 mg/ml syringe.
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. You say that you cannot walk by yourself or go to the bathroom and would end up deteriorating at home, as there is no one who can care for you. The Plan denied your request. The Plan says the enrollee is now at a level where she can transition from daily skilled services to
services that are provided intermittently. The Plan says that the enrollee no longer meets the criteria for daily skilled services.
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 necessary. Our physician reviewer found the enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. The enrollee is mobilizing and tending to activities of daily living with minimal supervision. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs, as a practical matter, can be provided 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve bioimpedance spectroscopy services.
You asked the Plan to pre-approve bioimpedance spectroscopy services. You say that the requested treatment is medically necessary. The Plan denied your request. The Plan says that medical studies have not proven that the requested test is helpful for evaluation of the enrollee's health problem.
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 bioimpedance spectroscopy services. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found bioimpedance spectroscopy for breast cancer related lymphedema assessment has become a standard of care for prevention and treatment. Clinical measurements are obtained initially to establish a baseline before breast cancer treatments and afterward at intervals to track changes during treatment. Alternatively, changes in arm circumference or volume relative to the contralateral normal limb can be performed. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of bioimpedance spectroscopy services have been met. Therefore, we decided that the Plan has to pre-approve bioimpedance spectroscopy 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
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable controller (E2377) with harness (E2313) and electronic connection (E2311) for a power wheelchair.
You asked the Plan to pre-approve an expandable controller with harness and electronic connection. You say that the requested items are a medical necessity for the enrollee. The Plan denied your request. The Plan says medical necessity rules for the requested items have not been met.
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 an expandable controller with harness and electronic connection. Our reviewer says that the requested items are not considered medically reasonable and necessary in this case. Our physician reviewer found that provided records document that the enrollee has 3/5 left upper extremity strength and is independent with personal hygiene and feeding, thus indicating that the enrollee has adequate upper extremity strength and function to operate the wheelchair's power options with their own switches. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an expandable controller with harness and electronic connection have not been met. Therefore, we decided that the Plan does not have to pre-approve an expandable controller (E2377) with harness (E2313) and electronic connection (E2311) for a power wheelchair
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0675 and E0673).
You asked the Plan to pay for a pneumatic compression device. You say that the items are medically necessary. The Plan denied your request. The Plan says the pneumatic compression device is not covered by Medicare to prevent deep vein thrombosis during and/or following surgery.
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0675 and E0673).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the stationary compressed oxygen equipment (E0431),
portable oxygen canisters (E0424) and infection control supplies (S8301) provided on December 11, 2020.
You asked the Plan to pay for the stationary compressed oxygen equipment, portable oxygen canisters and
infection control supplies. You say that you would like reconsideration based on the records submitted. The
Plan denied your request. The Plan says there is insufficient information to validate the services billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code. The rules also say that all claims for Durable
Medical Equipment, Prosthetic, and Orthotic Supplies (DMEPOS) require a written order/prescription from the
treating practitioner.
We find that CPT code S8301, E0431 and E0424 is not supported in the record. Specifically, the
documentation submitted does not include a physician ordered for the billed durable medical equipment.
Additionally, supplies used for anesthesia services are not separately payable. CPT code S8301 has a status
indicator of I. This means that CPT code S8301 is not valid for Medicare purposes. Based on this information,
we decided that Medicare rules for coverage of the stationary compressed oxygen equipment, portable oxygen
canisters and infection control supplies have not been met. Therefore, we decided that the Plan does not have to
pay for the stationary compressed oxygen equipment (E0431), portable oxygen canisters (E0424) and infection
control supplies (S8301) provided on December 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye exam and refraction provided on August 4, 2021.
You asked the Plan to pay for the eye exam and refraction. You say that you called to make sure the provider
was in-network and you were told they were. You say that this is the only time you've been denied for network
and you believe you should get one annual exam. The Plan denied your request. The Plan says this service is
not covered when performed by an out of network provider.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in
this case. The Plan covers these services when performed by an in-network provider.
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for
coverage of the eye exam and refraction have not been met. Specifically, the services were not received from a
network provider. Therefore, we decided that the Plan does not have to pay for the eye exam and refraction
provided on August 4, 2021.
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. You say that the enrollee has coronavirus, multiple respiratory comorbidities, and is at very high risk for complications. You say that the enrollee lives in an assisted living facility that is not able to care for coronavirus positive patients. You say that the enrollee is currently receiving physical and occupational therapy at a skilled level. The Plan denied your request. The Plan
says the guidelines for coverage have not been met. The Plan says that the enrollee can receive the care needed in another setting.
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 necessary. Our physician reviewer found the enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs are custodial and, as a practical matter, can be provided 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Monovisc.

You asked the Plan to pre-approve Monovisc. You say that the enrollee has a history of success on Monovisc. The Plan denied your request. The Plan says that step therapy requirements have not been met.

Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. Step therapy may only be applied to new prescriptions or administrations of Part B drugs for enrollees that are not actively receiving the affected medication. 

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 Monovisc. Our reviewer says that the requirements for coverage of Monovisc have been met. Our physician reviewer found this request for Monovisc is not a new prescription. It is noted that there is a proven history of success with Monovisc, which was started on October 14, 2021.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Monovisc have been met. Therefore, we decided that the Plan has to pre-approve Monovisc.

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: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve an ImpediMed L-Dex device.
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 that the services are not medically necessary.
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 these services. Our reviewer says that the services are medically necessary. Our physician reviewer found the enrollee has a history of breast cancer with axillary dissection. The use of the requested ImpediMed L-Dex device has been shown to be effective as an alternative method to monitor and/or diagnose lympadema in the medical literature. The services are reasonable and medically necessary for the enrollee 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 been met. Therefore, we decided that the Plan has to pre-approve an ImpediMed L-Dex device.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the medical eye exam you had on December 2, 2020.
You asked the Plan to waive the copayment for the medical eye exam. You say that according to your benefits, you should not have been charged a copayment for this exam. The Plan denied your request. The Plan says you were charged this copayment correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $30 copayment for medical eye exams. You have been asked to pay a $30 copayment for the medical eye exam. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the medical eye exam you had on December 2, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 10 additional skilled nursing visits.
You asked the Plan to pre-approve 10 additional skilled nursing visits. You say that the additional visits are medically necessary. The Plan denied your request. The Plan says the additional 10 skilled nursing 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 10 additional skilled nursing visits. Our reviewer says that the requested 10 additional skilled nursing visits are not medically necessary. Our physician reviewer found the provided medical records do not document that additional skilled nursing services beyond what have already been approved are required to effectively provide treatment, care, and/or services in order to improve the enrollee's condition, or to establish/perform a maintenance program to maintain the enrollee's condition and/or prevent deterioration. The reviewer found that the reported services to be provided by the wound clinic and the home health nursing visits already approved, records do not document why the services already approved are inadequate to treat the enrollee's condition. Therefore, the reviewer found that the additional 10 visits are not medically reasonable or 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 10 additional skilled nursing visits have not been met. Specifically, the file does not document why the services already approved are inadequate to treat the enrollee's condition. Therefore, we decided that the Plan does not have to pre-approve 10 additional skilled nursing visits.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a blepharoplasty.
You asked the Plan to pre-approve a blepharoplasty. You say that this surgery procedure is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage have not been met.
The Plan follows Medicare rules. Medicare rules say that blepharoplasty services will be considered medically reasonable and necessary when there is a minimum 12-degree loss of upper field vision. 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 blepharoplasty. Our reviewer says that the requested blepharoplasty is not medically reasonable and necessary. Our physician reviewer found that in this case, the record indicates that the enrollee has bilateral upper lid dermatochalasis. The record indicates that the enrollee has a visual field loss of six and seven degrees. The elements of the coverage criteria are not satisfied. he requested service cannot be recommended. 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 blepharoplasty have not been met. Therefore, we decided that the Plan does not have to pre-approve a blepharoplasty
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) scan of the lumbar spine.
You asked the Plan to pre-approve MRI services. You say that this request is medically reasonable for the enrollee's condition. The Plan denied your request. The Plan says the criteria for the requested MRI scan have not been met.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 MRI services. Our reviewer says that the requested MRI services are not medically reasonable and necessary. Our physician reviewer found that the medical records do not show documentation of new neurological deficits: lower extremity weakness, abnormal reflexes, abnormal sensory changes along a particular dermatome as documented on physical examination, evidence of Cauda EquinaSyndrome, bowel or bladder dysfunction, or new foot drop. There is no documentation provided indicating that the member has new or worsening objective neurologic deficits on exam, failure of conservative treatment for at least six (6) weeks within the last six (6) months, with progression or worsening of symptoms during the course of conservative therapy, an abnormal electromyography (EMG) or nerve conduction study (if performed) indicating evidence of lumbar radiculopathy. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of MRI services have not been met. Therefore, we decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) scan of the lumbar spine
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the core build up (D2950) for tooth # 28 provided on August 25, 2021.
You asked the Plan to pay for the dental service. You say that you were not advised of any exceptions. You also say that you were led to believe any and all bills would be paid. The Plan denied your request. The Plan says core build up is not listed as a covered service.
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 core build up for tooth # 28 is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the core build up (D2950) for tooth # 28 provided on August 25, 2021