Persius/hicric huggingface dataset:
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 inpatient rehabilitation is medically necessary for 
this enrollee. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. The 
enrollee's ongoing skilled therapy and nursing needs can be provided at a lower level of care.

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 the enrollee's nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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 this enrollee 
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 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 intracept procedure (CPT code(s): 22899, C9752, C9753), for the enrollee.

You asked the Plan to pre-approve the intracept procedure. You say that the services are medically necessary. The Plan denied your request. The Plan says the clinical value and effectiveness of the intracept procedure in the setting of chronic low back pain have not been demonstrated in the peer-reviewed literature. The Plan states more research is needed to show safety and efficacy of the procedure.

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 intracept procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the intracept procedure is experimental. More research is needed to show safety and efficacy of the device. 

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 intracept procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the intracept procedure (CPT code(s): 22899, C9752, C9753), for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Zilretta injection (CPT code J3304), for the enrollee.
You asked the Plan to pre-approve the injection. You say that the injection is medically necessary. The Plan denied your request. The Plan says the record provided shows the enrollee has had multiple Zilretta injections to their right knee. The Plan states this medicine is only approved for one-time use. The Plan states to be considered for coverage under Medicare Part B, a drug must meet Food and Drug Administration (FDA) indications for use. The Plan states since this is not approved by the FDA for more injections of the enrollee's knee, they cannot approve this request.
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 the injection. Our physician reviewer found Zilretta is not FDA approved for repeat use in the knee. 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 Zilretta injection (CPT code J3304), for the enrollee
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Oxycodone/APAP for the enrollee.

You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your request. The Plan says that this is not covered under Part B.

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 Oxycodone/APAP for the enrollee.

Benefits for this drug 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physical therapy provided from May 7, 2021, through July 8, 2021.

You asked the Plan to waive the copayment for physical therapy. You say that you are not responsible for the copayment if treatment is coronavirus related. The Plan denied your request. The Plan says the copayments applied 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 $25 copayment for each Medicare-covered outpatient rehabilitation service visit.

You have been asked to pay a $25 copayment for each physical therapy visit. Physical therapy falls within the "Outpatient rehabilitation services" benefit category. 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 physical therapy provided from May 7, 2021, through July 8, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Taltz.

You asked the Plan to pre-approve Taltz. You say that this could treat the enrollee's psoriasis. 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 Taltz.

Benefits for Taltz 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 Superion Interspinous device (CPT code(s): C1821, 22870, 22869), for the enrollee.

You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan denied your request. The Plan says the Vertiflex Superion Interspinous device is not indicated in this enrollee given multi-level disease, greater than two (2) levels, as seen on the magnetic resonance imaging (MRI) of the spine with noted central, foraminal, and recess stenosis from L2-S1 levels. The Plan states placement of Vertiflex at will not address the stenosis at the other levels.

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 services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental. More research is needed to show safety and efficacy of the device.

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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex Superion Interspinous device (CPT code(s): C1821, 22870, 22869), for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable oxygen tank (E1392).

You asked the Plan to pre-approve a portable oxygen tank. You say that you need this item for outside the home. The Plan denied your request. The Plan says you already have the most appropriate equipment that meets your needs; Medicare and the Plan do not cover portable oxygen systems for travel.

The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. 

The file shows that you have a portable oxygen tank. a portable oxygen tank serves the same purpose as a portable oxygen tank. Therefore, we decided that the Plan does not have to pre-approve a portable oxygen tank (E1392).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gabapentin.

You asked the Plan to pre-approve Gabapentin. 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 Gabapentin.

Benefits for Gabapentin 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 pay for a continuous positive airway pressure (CPAP) device 
provided on June 22, 2021.

You asked the Plan to pay for CPAP device. You say that this was processed by the Plan in error causing a 
denial. The Plan denied your request. The Plan says the denial of payment for this item is correct, because code 
E0601 was not billed with the appropriate modifiers.

The Plan must follow Medicare rules. Medicare rules say that capped rental items are billed using the modifier 
-RR to indicate a rental and one of the modifiers -KH, -KI, or -KJ to indicate which month of the rental period 
is being billed for payment calculation. 

We looked at the file and Medicare rules. Code E0601 was billed with modifier -RR; however, this claim has 
not been billed with the applicable use of modifier -KH, -KI, or -KJ. Based on this information, we decided that 
Medicare rules for coverage of CPAP device have not been met. Therefore, we decided that the Plan does not 
have to pay for a continuous positive airway pressure (CPAP) device provided on June 22, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve five (5) additional home skilled nursing visit(s) (CPT 
code G0299), for the enrollee.

You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says the enrollee's medical conditions appear stable, there have been no recent changes to 
their treatment plan or their medications, and the enrollee's records show that their medical conditions, 
medication management, pain management, diet, and household safety have been reviewed with the enrollee 
and their caregiver(s). The Plan states their records do not support the need for a skilled nurse to make more 
visits.

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 the services. Our physician reviewer 
found there is no documentation that skilled nursing services 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 patient's condition and/or prevent deterioration. Records do not document any acute or unstable 
medical conditions or changes in medication or treatment which would necessitate any further skilled nursing 
visits beyond what have already been approved. No medical notes from the enrollee's treating physician (or 
assisted living provider) are included documenting an order or need for additional skilled nursing services.

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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve five (5) additional home skilled nursing visit(s) (CPT code G0299), for the enrollee.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve magnetic resonance angiography (MRA) of the head/brain.
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 MRA is covered when specific criteria are met. 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 increasing headaches and right jaw pain after recent blunt trauma. The Plan has approved magnetic resonance imaging (MRI) but the MRA is on hold, pending results of the MRI. This is not reasonable, as the MRA is still indicated even if MRI is negatie. The MRA is appropriate and 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 been met. Therefore, we decided that the Plan has to pre-approve magnetic resonance angiography (MRA) of the head/brain.
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two removals of torus mandibularis (D7473 x2).
You asked the Plan to pre-approve the removals of torus mandibularis. 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 two removals of torus mandibularis (D7473 x2).
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Genvisc or Supartz injection.
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says the physician has not indicated that the formulary alternatives are clinically inappropriate.
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 the injection. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found the plan requires a trial of Euflexxa or Durolane before they will approve the requested drug. In this case, you have not tried and failed the required drug s. There is no documentation provided indicating that the plan's required drugs would likely be less effective and/or likely have adverse effects for the 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 injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a Genvisc or Supartz injection
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pontic (D6240) and two retainer crowns (D6750 x2).
You asked the Plan to pre-approve the pontic and retainer crowns. The Plan denied your request. The Plan says these services are not covered 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 a pontic (D6240) and two retainer crowns (D6750 x2).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a FreeStyle Libre 14 Day Sensor Kit.
You asked the Plan to pre-approve the FreeStyle Libre 14 Day Sensor Kit. The Plan denied your request. The Plan says the criteria for coverage have not been met.
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the FreeStyle Libre 14 Day Sensor Kit have not been met. Therefore, we decided that the Plan does not have to pre-approve a FreeStyle Libre 14 Day Sensor Kit.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor for the enrollee.
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 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 monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two removals of torus mandibularis (D7473 x2).

You asked the Plan to pre-approve the removals of torus mandibularis. You say that you need your jaw ground down so you can get dentures because the bone is sticking out. 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 two removals of torus mandibularis (D7473 x2).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve medical nutrition therapy services.
You asked the Plan to pre-approve medical nutrition therapy services. You say that you were recommended to lose weight with the help of a nutritionist. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because you do not have a condition for which medical nutrition therapy is covered.
The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services only for enrollees with renal disease or diabetes. Records do not show that you suffer from renal disease or diabetes. Therefore, we decided that the Plan does not have to pre-approve medical nutrition therapy services.