Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the outpatient evaluations to be provided by an out-of-
network (OON) provider.
You asked the Plan to pre-approve the outpatient evaluations. You say that the non-contract facility has the best
doctors. 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. Therefore, we decided that the Plan does not have to pre-approve
the outpatient evaluations to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a comprehensive metabolic panel (80053) provided on
September 11, 2021.
You asked the Plan to pay for a comprehensive metabolic panel. You say that this is supported in the records.
The Plan denied your request. The Plan says this was performed for screening purposes.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed in the Medicare rules section, are not covered.
The test at issue in this appeal, a comprehensive metabolic panel, was requested solely for screening purposes.
Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not
have to pay for a comprehensive metabolic panel (80053) provided on September 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown - porcelain/ceramic (D2740) for tooth #25.
You asked the Plan to pre-approve a crown. You say that a big chunk of your tooth is gone, and it is sensitive.
The Plan denied your request. The Plan says the x-rays do not show evidence of recurrent decay or open
margins on the existing crown on tooth #25. It is not medically necessary to replace the crown.
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 a crown 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 a crown. Our reviewer says that a
crown for tooth #25 is not medically necessary. Our physician reviewer found that in this case, the record
indicates that the enrollee has a crown on tooth #25. The record does not indicate that there is a functional
problem with the crown. The requested service is cosmetic in nature. The elements of the coverage criteria 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
the Plan's rules for coverage of a crown have not been met. Therefore, we decided that the Plan does not have
to pre-approve a crown - porcelain/ceramic (D2740) for tooth #25.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Carboplatin, Pemetrexed, and Pembrolizumab.

You asked the Plan to pre-approve the requested drugs. You say that the enrollee needs concurrent treatment. The Plan denied your request. The Plan says if a drug did not help, it should not be restarted.

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 requested drugs. Our physician reviewer found that the enrollee has stage IV non-small cell lung cancer. The requested drug regimen is not FDA-approved for the enrollee's diagnosis. The use is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. Adding chemotherapy to immunotherapy after progression has not improved outcomes. The use is not listed as not indicated, not supported or not recommended in any of the compendia. The documentation does not support that the requested drug is safe and effective and otherwise reasonable and necessary for this enrollee.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the requested drugs have not been met. Therefore, we decided that the Plan does not have to pre-approve Carboplatin, Pemetrexed, and Pembrolizumab.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core buildup, including any pins when required
(D2950).
You asked the Plan to pre-approve core buildup. You say that a plan representative told you an incorrect code
was used. The Plan denied your request. The Plan says this service is not covered under your benefits.
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 core
buildup, including any pins when required (D2950).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a sacroiliac joint (SIJ) arthrography injection.
You asked the Plan to pre-approve the injection. The Plan denied your request. The Plan says this 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 injection. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found that criteria for the use of SIJ blocks include that the enrollee has had and failed at least 4-6 weeks of
aggressive conservative therapy including, physical therapy (PT), home exercise and medication management.
There should be evidence of a clinical picture that is suggestive of sacroiliac injury and/or disease. At least
three positive exam findings of SI joint dysfunction should be present on physical exam such as: Patrick's test,
thigh thrust, SI compression test, Yeoman's test, or Gaenslan's test. There was no documentation of these exam
findings. In addition, the enrollee's most recent SI Joint injection was on November 13, 2020, and clinical
records indicate it provided 10% relief. The requested SI Joint arthrography injection in this case is 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 the injection have not been met. Therefore, we decided that the Plan does not
have to pre-approve a sacroiliac joint (SIJ) arthrography injection.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a specialist office visit (99203, 99213) to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve a specialist office visit. You say that your symptoms continue to escalate. You also say you have been told by both your gastroenterologists (GI) and the surgeon you are asking to see, that surgery is needed and quickly. You also say that your gastroesophageal reflux disease is causing fluid in your lungs and if the surgery is not done quickly, your situation will turn life-threatening. The Plan denied your request. The Plan says the requested service was determined to be available within the Plan's primary network. The Plan also says that they recommend you see an in-network doctor and a referral has been approved for you to see that doctor.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a specialist office visit (99203, 99213) to be provided by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy services to be provided by the requested out-of-network provider.

You asked the Plan to pre-approve physical therapy services. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the Plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the Plan.

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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve physical therapy services to be provided by the requested out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xarelto.

You asked the Plan to pre-approve Xarelto. You say that this is medically necessary. The Plan denied your request. The Plan says coverage of this medication is the responsibility of the enrollee's prescription drug plan.

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 Xarelto.

Benefits for Xarelto 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor.
You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your
request. The Plan says the criteria is not met.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based
on the blood glucose testing results and have had an in-person visit with their treating physician to assesses
adherence to their CGM regimen and diabetes treatment plan.
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood
glucose testing at least four times per day or use insulin with at least three daily injections. Based on this
information, we decided that Medicare rules for coverage of the monitor have not been met. Therefore, we
decided that the Plan does not have to pre-approve a continuous glucose monitor.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor.
You asked the Plan to pre-approve the requested services. You say that you stick your fingers a lot. The Plan
denied your request. The Plan says the monitor is not medically necessary and not covered.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations,
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment
plan.
We looked at the file and Medicare rules. The documentation does not indicate that you use insulin with at least
three daily injections or require frequent self-adjustment of insulin dosage based on the blood glucose testing
results. 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 continuous glucose monitor.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a sacroiliac joint injection.

You asked the Plan to pre-approve the requested services. You say that the service is necessary for daily functioning. The Plan denied your request. The Plan says the services are 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 requested services. Our physician reviewer found that the enrollee is status post lumbar fusion. She has left sacroiliitis. She takes Cymbalta and Lyrica for pain. She had a prior sacroiliac joint injection with 3% pain relief for 2-3 days. The request is for a repeat injection. There was a poor response to the prior injection. Therefore, it is unreasonable to repeat it. The request is 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 the requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve a sacroiliac joint injection.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an oscillation and lung expansion device.
You asked the Plan to pre-approve the requested device. You say that the requested system is a more effective
airway clearance. The Plan denied your request. The Plan says the enrollee is non-compliant with his current
therapy.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
The file shows that a Volara system was requested. 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 device. Our physician reviewer found that the enrollee has severe bronchiectasis
with recurrent exacerbations. He has a high-frequency chest wall oscillation device (HFCWOD) and nebulized
saline, but there are reportedly problems with compliance in their use. The Volara System combines intra-
airway oscillations, end-expiratory positive pressure, and nebulization. There is insufficient evidence that it is
effective, or that it is more effective than HFCWOD, in the treatment of bronchiectasis. The nebulization would
duplicate his current treatment. Therefore, the Volara system is not 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 device have not been met. Therefore, we decided that the Plan
does not have to pre-approve an oscillation and lung expansion device.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Otezla (J8499).

You asked the Plan to pre-approve the Otezla. You say that the drug is medically necessary. The Plan denied your request. The Plan says Otezla is a self-administered drug.

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 the Otezla (J8499).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the chiropractic manipulative treatment to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the chiropractic manipulative treatment. You say that you were led to believe this provider was in-network. 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. Therefore, we decided that the Plan does not have to pre-approve the chiropractic manipulative treatment to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.
You asked the Plan to pre-approve a shower chair. You say that you are unable to stand. The Plan denied your
request. The Plan says this item is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are
not primarily medical in nature.
While a shower chair 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 shower chair.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says you do not have
daily skilled 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 SNF services. Our physician reviewer
found that from a nursing perspective, you received oral medications, had stable vital signs, and your lungs
were clear. There are no identifiable skilled nursing service needs. Regarding rehabilitation services, you were
at a minimal to moderate assist level with functional mobility. You required varying assist with activities of
daily living. There are no identifiable skilled therapy service needs. You do not require skilled nursing or
therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for an
inpatient basis in a SNF setting.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve botulinum toxin (Botox) every 10 weeks for one year.
You asked the Plan to pre-approve Botox. You say that you would like the plan to reconsider their denial. The
Plan denied your request. The Plan says that the requested drug is not medically necessary.
The Plan follows Medicare rules. Medicare rules say that Botox is covered for certain 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 Botox. Our reviewer says that the
documentation does not support that the Our physician reviewer found the enrollee has a diagnosis of Chronic
migraine without aura, intractable, without status migrainosus. It is documented that the enrollee has
consistently noted a wearing off of the beneficial effects of Botox. In the few weeks before the enrollee is due
for Botox, the enrollee gets almost daily headaches that often interfere with activities. The Botox is being used
for a medically accepted indication. While retreatment with Botox is typically every 12 weeks, the enrollee's
neurologist writes that she really thinks the enrollee would benefit from getting the injections every 10 weeks
because the headaches are so bad in the weeks before the enrollee is due. Therefore, the enrollee meets criteria
for the requested drug.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Botox have been met. Therefore, we decided that the Plan has to pre-approve
botulinum toxin (Botox) every 10 weeks for one year.
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.