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

We decided that the Plan does not have to pre-approve Opdivo and Yervoy.
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 left upper lobe squamous cell carcinoma. The combination of Yervoy and Opdivo is not FDA-approved for the treatment of recurrent non-small cell lung cancer or small cell lung cancer beyond first line treatment. The enrollee has recurrent disease after two prior lines of therapy, including prior immunotherapy. Yervoy and Opdivo is not supported by major drug compendia and is not reasonable and medically necessary or safe and effective. 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 Opdivo and Yervoy.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bone replacement graft for ridge preservation
(D7953).
You asked the Plan to pre-approve the bone replacement graft. The Plan denied your request. The Plan says
this service is 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 a
bone replacement graft for ridge preservation (D7953).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the arthrocentesis, aspiration and/or injection, of a major joint or bursa (20610 x 2) and the Hyaluronan or derivative injection, 1 mg (J7325) provided on April 20, 2021.
You asked the Plan to waive the cost share. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the cost share has been applied correctly to the services provided.
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 a specialist visit and a 20% coinsurance of the cost for Medicare Part B drugs.
You have been asked to pay $95.02 which includes a $30 copayment for the specialist visit and $65.02 (Plan allowed amount of $325.12 x 20% coinsurance) for the Medicare Part B drug injection provided. 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 cost share for the arthrocentesis, aspiration and/or injection, of a major joint or bursa (20610 x 2) and the Hyaluronan or derivative injection, 1 mg (J7325) provided on April 20, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics (L9900). You say that the you need the heel lift due to leg length discrepancy that causes lower back pain. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental services (D6245, D6740).
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your
request. The Plan says this is not a covered 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
dental services (D6245, D6740).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
You asked the Plan to pre-approve continued services. You say that the enrollee has not reached her baseline. The Plan denied your request. The Plan says there are no noted daily skilled complex nursing or therapy needs.
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 services. Our physician reviewer found that the enrollee is at a minimal assist level for bed mobility and transfers, supervision for activities of daily living, and at contact guard assist for ambulating using a four-wheel walker. There are no daily skilled nursing needs. She does not require daily skilled therapies in an inpatient 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 continued services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group three heavy duty power wheelchair and accessories.
You asked the Plan to pre-approve a group three heavy duty power wheelchair and accessories. You say that you feel these items are medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested items.
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 rules also say that the enrollee must be able to safely operate the power wheelchair and live in an environment with adequate space and access to use the power wheelchair within the home. While the file does show that the enrollee has a mobility limitation that is due to a neurological condition, myopathy or congenital skeletal deformity, the documentation does not support that the enrollee would be able to safely operate the power wheelchair and the enrollee does not live in an environment that is conducive to maneuvering a power wheelchair. Therefore, we decided that the Plan does not have to pre-approve a group three heavy duty power wheelchair and accessories
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an auricular stimulator.
You asked the Plan to pre-approve an auricular stimulator. The Plan denied your request. The Plan says this is not a covered service.
The Plan must follow Medicare rules. Medicare rules say that the service for auricular peripheral nerve stimulation will be denied as non-covered. We looked at the file and Medicare rules. Per A55240, the requested procedure is not covered. Based on this information, we decided that Medicare rules for coverage of an auricular stimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve an auricular stimulator
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 it is difficult for you to get up from the
toilet and require assistance. The Plan denied your request. The Plan says the requested 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 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 raised toilet seat.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued continuous positive airway pressure device (CPAP) coverage.

You asked the Plan to pre-approve continued CPAP coverage. You say that you feel this should be covered. The Plan denied your request. The Plan says you do not meet criteria for the requested continued use.

The Plan must follow Medicare rules. Medicare rules say that continued CPAP coverage is only covered when adherence to therapy of use of PAP greater than or equal to 4 hours per night on 70% of nights during a consecutive thirty (30) day period.

We looked at the file and Medicare rules. Review of the file does not support that you used your device for 4 hours per night on 70% of the nights during a non-stop 30 day period. Based on this information, we decided that Medicare rules for coverage of continued CPAP coverage have not been met. Therefore, we decided that the Plan does not have to pre-approve continued continuous positive airway pressure device (CPAP) coverage.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve proton beam radiation therapy (PBRT).
You asked the Plan to pre-approve PBRT. You say that PBRT is medically necessary and supported by the records provided. The Plan denied your request. The Plan says the standard of care for radiation therapy of prostate cancer is standard radiation therapy including Intensity modulated radiation therapy (IMRT). The Plan says that there is no indication that IMRT has failed or would not be appropriate for the enrollee.
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 PBRT. Our reviewer says that PBRT is not considered medically reasonable and necessary in this case. Our physician reviewer found any potential benefit or detriment of proton therapy over standard IMRT is an investigational question. Other treatment approaches are also highly effective and well tolerated. Thus, whether proton therapy affords a benefit over other standard approaches for prostate cancer is an area of investigation and remains controversial. The generally accepted standard of care for prostate cancer is to only offer proton beam therapy on clinical trials, and to not routinely offer it to patients.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of PBRT have not been met. Therefore, we decided that the Plan does not have to pre-approve proton beam radiation therapy (PBRT).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) services.
You asked the Plan to pre-approve the RFA services. You say that the records provided support the need for the RFA services in dispute. The Plan denied your request. The Plan says there are no medial branch nerves level C1-C2. The Plan says that the requested service is not medically necessary.
The Plan follows Medicare rules. Medicare rules say that RFA services are covered for certain medical indications. 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 RFA services. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the requested is for the C1-C2 joint and the atlanto-axial joint is not characterized as a facet joint. Spinal facet joints are described from C2-C3 and below. Furthermore, the enrollee did not have at least two diagnostic blocks achieving a minimum of 80% improvement in her pain. 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 RFA services have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) services.
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 LTACH services are medically necessary. The Plan denied your request. The Plan says based on Medicare guidelines, the LTACH services do not meet the requirements for approval.

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 that the enrollee was admitted with urosepsis and required intubation for respiratory failure. The enrollee is improving and requires nasal cannula oxygen and routine topical wound care of a heal ulcer. The enrollee continues to receive acute care services, and these have not been denied. The medical record does not indicate that the enrollee requires services that she is not currently receiving but that would be available at the LTACH facility. he elements of the coverage rules are not satisfied. The 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 the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings.
You asked the Plan to pre-approve the compression stockings. You say that you need these stockings because
your legs are swollen. The Plan denied your request. The Plan says these are not covered for your condition.
The Plan must follow Medicare rules. Medicare rules say that the requested compression stockings are covered
only when they are used to treat an open venous stasis ulcer. Medicare rules also say that compression
bandages and gradient compression wraps are covered only when they are used as dressings over a qualifying
wound.
The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you
do not have a medical condition for which compression stockings can be covered or paid for by Medicare.
Therefore, we decided that the Plan does not have to pre-approve compression stockings.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that you are in need of physical therapy because you are getting worse, and you are a risk for falls. The Plan denied your request. The Plan says you do not meet Medicare criteria for an IRF admission.
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. You have a past
medical history of lumbar spine surgery in June 2021 and you are currently living at home with weakness and trouble walking. Your medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve IRF admission and services
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve extractions.

You asked the Plan to pre-approve the extractions. You say that you have lost weight, have vitamin deficiency, collapsing facial muscles and are swallowing blood. You say that this constitutes medical necessity for the extractions. The Plan denied your request. The Plan says extraction coverage is limited to trauma/accident to the jaw or in preparation for radiation due to malignancy.

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 extractions.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gelsyn.
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 step therapy requirement is not 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. 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 records show that you have knee osteoarthritis. You have not tried and failed the Plan's required drugs, Synvisc One or Euflexxa. The records do not show that the required drugs would be less effective or cannot be taken; therefore, Gelsyn 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 Gelsyn.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve posterior tibial neurostimulation (PTNS) and associated office services.

You asked the Plan to pre-approve PTNS and office services. You say that this will correct your condition. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because the record does not show that you have tried anticholinergic drug therapy or have a contraindication to anticholinergic drug therapy.

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 PTNS and office services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the available documentation does not support that standard anticholinergic drug therapy has been tried and failed, or that you have intolerance to anticholinergic drug therapy despite best attempts at management. Consequently, the PTNS and related services are not medically reasonable and 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 PTNS and office services have not been met. Therefore, we decided that the Plan does not have to pre-approve posterior tibial neurostimulation (PTNS) and associated office services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the periodontal maintenance (D4910) provided on July 2, 2021.
You asked the Plan to waive the copayment for the periodontal maintenance. You say that you were overcharged for this service and would like to be refunded. The Plan denied your request. The Plan says you were presented with and signed a treatment plan for the periodontal maintenance to be completed. The Plan also says that periodontal maintenance is covered with a copayment of $45.00.
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, you are responsible for a $45 coinsurance for periodontal maintenance (D4910). The record shows that you were given and signed a financial agreement with the provider's office, which stated your estimated responsibility would be $45.00. Therefore, we decided that the Plan does not have to waive the copayment for the periodontal maintenance (D4910) provided on July 2, 2021