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

We decided that the Plan does not have to pre-approve Entyvio (J3380).
You asked the Plan to pre-approve Entyvio. You say that this drug is medically reasonable and necessary. The Plan denied your request. The Plan says the step therapy criteria for Entyvio 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. 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 Entyvio. Our reviewer says that the requested drug is not medically reasonable and necessary. Our physician reviewer found the enrollee has a diagnosis of ulcerative (chronic) pancolitis with other complication. In this case, the Plan has not tried and failed the Plan's required step therapy drugs Inflectra, Remicade and Stelara. In addition, the case file does not contain documentation that Inflectra or Remicade and Stelara would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Entyvio have not been met. Therefore, we decided that the Plan does not have to pre-approve Entyvio (J3380).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cystourethroscopy, with insertion of permanent urethral stent and Temporarily Implanted Nitinol Device (ITIND).
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied your request. The Plan says medical studies haven't proven that this device is helpful for treatment of the health problem.
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 procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found long term medical studies have not confirmed that this device is effective for management of benign prostatic hyperplasia. The 2021 American Urology Association guidelines do not support the use of this 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 procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve cystourethroscopy, with insertion of permanent urethral stent and Temporarily Implanted Nitinol Device (ITIND).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a second opinion for an ophthalmology evaluation to be 
provided by one of the requested out-of-network providers. 
 
You asked the Plan to pre-approve a second opinion for an ophthalmology evaluation to be provided by one of 
the requested out-of-network providers. You say that you received false information related to your vision in 
the past and that is why you prefer to have vision care services with one of the requested providers. The Plan 
denied your request. The Plan says the service is available within the network and your condition is not an 
emergency. 
 
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 a second 
opinion for an ophthalmology evaluation to be provided by one of the requested out-of-network providers.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation services.
You asked the Plan to pre-approve the requested services. You say that you are in pain. The Plan denied your
request. The Plan says the requested services have not been scientifically demonstrated to improve clinical
outcomes.
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 you have bilateral knee osteoarthritis. You take Tylenol for pain. You had an intra-articular
steroid injection which provided one week of pain relief. The request is for radiofrequency ablation of the
genicular nerves. This is an experimental/investigational procedure that is the subject of ongoing clinical trials.
Therefore, the request is considered 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 radiofrequency ablation services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation services.
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the
request does not meet the criteria.
The Plan must follow Medicare rules. Medicare rules say that facet joint interventions are only covered under
certain medical indications.
We looked at the file and Medicare rules. The records show that the enrollee received radiofrequency ablation
services in the lumbar region on April 13, 2021, and April 29, 2021. For each spinal region, no more than 2
radiofrequency sessions will be covered per rolling 12 months. 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 radiofrequency ablation services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay and additional amount for the inpatient care provided from April 2, 2020, to April 4, 2020.
You asked the Plan to pay and additional amount for the inpatient care. You say that the claim was coded appropriately. The Plan denied your request. The Plan says the provided documentation does not support the billing of the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) code, G93.41, metabolic encephalopathy.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes. In this case, you billed the inpatient services provided with ICD-10-CM code, G93.41, metabolic encephalopathy. 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 pay and additional amount for the inpatient care. Our physician reviewer found the provided documentation indicates that the enrollee was admitted to the hospital with altered mentation and found to have systemic inflammatory response syndrome. The enrollee's condition was documented to have improved while still in the emergency department, and was awake, alert and oriented x3 upon admission to the hospital. The enrollee remained at baseline mentation, oriented x3, throughout the remainder of the hospitalization stay. In summary, G93.41, metabolic encephalopathy was not substantiated a valid diagnosis. Therefore, the reviewer found that the provided documentation did not support the billing of ICD-10-CM code, G93.41 metabolic encephalopathy, as the primary diagnosis. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay and additional amount for the inpatient care provided from April 2, 2020, to April 4, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xarelto.
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 Xarelto.
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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Brinzolamide for the enrollee. 
 
You asked the Plan to pre-approve this drug. You say that this is medically necessary for the enrollee. 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 Brinzolamide 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the enrollee has medical needs that required care in the IRF. The Plan denied your request. The Plan says the guidelines for coverage of IRF care have not been met. The Plan says that the enrollee could receive the care needed in another setting.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.
Our physician reviewer found the 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. The enrollee was admitted for sepsis and surgical management of perforated diverticulitis with peritonitis. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does 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 the 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of your nursing, medical and rehabilitation needs do not require 
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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. 
 
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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says there has been no change in function that requires daily skilled nursing or therapy.
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 the admission. Our reviewer says that the requested admission is not medically reasonable or necessary. Our physician reviewer found there are no identifiable skilled therapy service or skilled nursing service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 the admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for additional supplies, materials, and clinical staff time provided from May 27, 2021, through July 8, 2021.
You asked the Plan to pay for additional supplies, materials, and clinical staff time. The Plan denied your request. The Plan says CMS assigns a status code of B for this code which states that payment for covered services are always bundled into payment for other services not specified. Code 99072 will be disallowed when billed in conjunction with another CPT and/or HCPCS procedure code.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 99072 is additional supplies, materials, and clinical staff time over and above those usually included in an office visit or other non-facility service(s), when performed during a Public Health Emergency, as defined by law, due to respiratory-transmitted infectious disease.
We find that CPT code 99072 is not supported in the medical record. Specifically, per the Physician Fee Schedule, CPT code 99072 has a status indicator of B. This means that payment for CPT code 99072 is always bundled into the payment for another service or procedure. Based on this information, we decided that Medicare rules for coverage of the additional supplies have not been met. Therefore, we decided that the Plan does not have to pay for additional supplies, materials, and clinical staff time provided from May 27, 2021, through July 8, 2021
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sensors for a continuous glucose monitor (CGM).
You asked the Plan to pre-approve these services. You say that you need the device daily to keep your A1C controlled. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that a sensor described by code A9276 is for a non-therapeutic CGM.
We looked at the file and Medicare rules. The requested sensor is described by code A9276 and is for use with a non-therapeutic CGM. This item is not covered by Medicare. 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 sensors for a continuous glucose monitor (CGM).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung cancer screening.
You asked the Plan to pre-approve the requested LDCT scan. You say that the medical records provided will show proof of medical necessity of the requested service. The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria as the enrollee stopped tobacco use 18 years ago.
The Plan must follow Medicare rules. The rules say that Medicare covers one annual LDCT scan for lung cancer screening for enrollees who meet all the criteria described in the Medicare rules section of this letter.
We reviewed the file and the Medicare rules. We find that the enrollee does not meet the criteria as tobacco use had stopped 18 years ago. Therefore, we decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung cancer screening.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of GenVisc.
You asked the Plan to pre-approve GenVisc. You say that this is medically necessary for the enrollee's
condition. The Plan denied your request. The Plan says the denial of authorization for this drug is correct,
because the enrollee does not meet the requirements for repeat injection.
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 GenVisc. Our reviewer says that the
enrollee does not meet the Medicare criteria for GenVisc. Our physician reviewer found there is no medical
literature that supports the repeat of viscosupplementation after failure of a different agent. This 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 GenVisc have not been met. Therefore, we decided that the Plan does not have
to pre-approve use of GenVisc.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an inpatient admission for a Maze procedure for atrial fibrillation.
You asked the Plan to pre-approve an inpatient admission for a Maze procedure for atrial fibrillation. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 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 inpatient admission for a Maze procedure for atrial fibrillation. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the record does not indicate that the enrollee is undergoing concomitant open heart surgery. The record provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. The elements of the coverage criteria are not satisfied. The requested service is not 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 an inpatient admission for a Maze procedure for atrial fibrillation have not been met. Therefore, we decided that the Plan does not have to pre-approve an inpatient admission for a Maze procedure for atrial fibrillation.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Abraxane for the enrollee.
You asked the Plan to pre-approve Abraxane. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says that there is no indication their preferred drugs would likely be less effective, and/or cause adverse effects for the member.
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 Abraxane. Our reviewer says that Abraxane is not medically reasonable and necessary for the enrollee. The Plan requires a trial of Taxol (paclitaxel) or Taxotere (docetaxel) or a documented contraindication to standard hypersensitivity premedication before they will approve the requested drug. In this case, the patient has not tried and failed the required drug(s). There is no documentation provided indicating that the plan's required drug(s) would likely be less effective and/or likely have adverse effects for the enrollee. Our physician reviewer found that the enrollee's condition does not meet step therapy criteria for Abraxane. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Abraxane have not been met. Therefore, we decided that the Plan does not have to pre-approve Abraxane for the enrollee.