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

We decided that the Plan does not have to pre-approve Euflexxa.
You asked the Plan to pre-approve Euflexxa. You say that you would like the plan to reconsider their denial.
The Plan denied your request. The Plan says the requested drug does not meet step therapy criteria.
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 Euflexxa. Our reviewer says that the
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer
found the enrollee has a diagnosis of Bilateral post-traumatic osteoarthritis of the knees. The documentation
does not support that the enrollee has tried and failed Orthovisc and Supartz FX. The documentation does not
support that Orthovisc and Supartz FX 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 Euflexxa have not been met. Therefore, we decided that the Plan does not have
to pre-approve Euflexxa.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Injectafer (J1439).
You asked the Plan to pre-approve Injectafer. You say that this is medically necessary. The Plan denied your
request. The Plan says step therapy requirements have not been met.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain
Part B medications.
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 Injectafer. Our reviewer says that the
requirements for coverage of Injectafer have not been met. Our physician reviewer found the Plan requires a
trial of INFeD (iron dextran) and Venofer (iron sucrose) before they will approve the requested drug. The
record does not show that the enrollee has tried these drugs. The documentation also does not support that
INFeD and Venofer would likely be less effective or 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 Injectafer have not been met. Therefore, we decided that the Plan does not have
to pre-approve Injectafer (J1439).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Symbicort (J3535).
You asked the Plan to pre-approve Symbicort. You say that Symbicort is medically necessary. The Plan denied your request. The Plan says this drug is not eligible for coverage under the Part B medical benefit.
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 Symbicort (J3535).
Benefits for Symbicort 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) scans of the pelvis (72195, 72196, 72197).
You asked the Plan to pre-approve MRI scans of the pelvis. You say that the requested service is a medical necessity for the enrollee. The Plan denied your request. The Plan says medical necessity rules for the requested service have not been met.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve MRI scans of the pelvis. Our reviewer says that the requested services are not medically reasonable and necessary in this case. Our physician reviewer found that there is no explanation given as to why a computed tomography (CT) scan could not be performed. The specific need for the requested services has not been addressed by the ordering physician.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of MRI scans of the pelvis have not been met. Therefore, we decided that the Plan
does not have to pre-approve magnetic resonance imaging (MRI) scans of the pelvis (72195, 72196, 72197).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa (J7623).
You asked the Plan to pre-approve Euflexxa. The Plan denied your request. The Plan says the enrollee has not completed physical therapy.
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 Euflexxa. Our reviewer says that the requested Euflexxa is not medically necessary. Our physician reviewer found the provided documentation shows that the enrollee has not undergone any course of physical therapy. The reviewer found that the documentation does not support that Euflexxa is medically reasonable or necessary for the enrollee. The reviewer also found that the documentation does not support that the Euflexxa is safe and effective for the patient. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Euflexxa have not been met. Specifically, the file does not show that you have completed physical therapy. Therefore, we decided that the Plan does not have to pre-approve Euflexxa (J7623).
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 services are medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
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 there is not a reasonable expectation that this patient 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional PT visits.
You asked the Plan to pre-approve additional PT visits. You say that additional PT is medically necessary. The Plan denied your request. The Plan says additional PT is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.
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 additional PT visits.
Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the documentation does not support and is not medically necessary for coverage for additional therapy visits. The requested therapy it not generally accepted as specific and effective therapy for the enrollee's condition. The records do not demonstrate that the unique skills of a professional therapist are required to provide treatment safely and effectively, that the services can be safely and effectively performed only by a therapist, or for physical therapy and occupational therapy, by or under the supervision of a therapist. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of additional PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve additional PT visits.
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 these services are medically necessary. The Plan denied your request. The Plan says that your acute medical conditions are not yet stable.
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. 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 were admitted for hemiplegia and surgical
management of a meningioma. 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 you have a need for physical and/or occupational therapy, there is no documentation of a need for an intensive 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. Our physician reviewer found that your condition does not meet Medicare criteria for IRF care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Benlysta.
You asked the Plan to pre-approve Benlysta. You say that the requested Benlysta is medically necessary. The Plan denied your request. The Plan says the requested Benlysta is 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 Benlysta. Our reviewer says that the requested Benlysta is not medically necessary. Our physician reviewer found the enrollee has a diagnosis of Systemic lupus erythematosus, unspecified, since 2018. The enrollee is being treated with Mycophenolate, Plaquenil, and Benlysta. The enrollee's CRP is elevated. The documentation in the case file in insufficient to demonstrate that Benlysta (Belimumab) is medically reasonable and necessary for the enrollee in this case. Benlysta (belimumab) is indicated for the treatment of patients aged 5 years and older with active, autoantibody-positive systemic lupus erythematosus who are receiving standard therapy, and adult patients with active lupus nephritis who are receiving standard therapy. The case file does not contain documentation of a diagnosis of autoantibody-positive systemic lupus erythematosus, or active lupus nephritis. The documentation is insufficient to support that Benlysta is reasonably expected to be safe and effective 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 Benlysta have not been met. Therefore, we decided that the Plan does not have to pre-approve Benlysta.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health services.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the 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 reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found in this case, this case, the documentation doesn't support that you require additional skilled nursing services to provide treatment that is medically necessary. You do not require additional skilled nursing services to effectively provide treatment, care, and/or services in order to improve your condition, perform a maintenance program to maintain your condition and/or prevent deterioration. You have been medically stable without any recent exacerbations of chronic medical problems or hospitalizations. The requested home health services are 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve home health services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Accu-Chek Aviva Plus strips.
You asked the Plan to pre-approve the strips. You say that this is medically necessary. The Plan denied your request. The Plan says there is no adequate trial and failure of the preferred brands.
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 strips. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no rationale in the records for why the preferred brand would not suffice in this case. Without this information, use of the requested brand of test strips would not be 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 strips have not been met. Therefore, we decided that the Plan does not have to pre-approve Accu-Chek Aviva Plus strips.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an interspinous stabilization device.
You asked the Plan to pre-approve the requested services. You say that the enrollee did not get good relief with conservative management. The Plan denied your request. The Plan says research has not found it to be helpful for the enrollee's condition.
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 requested device is considered experimental. More research is needed to show safety and efficacy. Therefore, the requested services are not medically reasonable or necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve an interspinous stabilization device
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (D2752), endodontic therapy (D3320), simple extractions (D7140), maxillary partial denture (D5213), and mandibular partial denture (D5214).
You asked the Plan to pre-approve the crown, endodontic therapy, simple extractions, maxillary partial denture, and mandibular partial denture. You say that you need these services because you are having trouble eating and speaking. The Plan denied your request. The Plan says these services are not covered under your benefit plan.
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 crown (D2752), endodontic therapy (D3320), simple extractions (D7140), maxillary partial denture (D5213), and mandibular partial denture (D5214).
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 enrollee does not meet criteria for 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 enrollee does not meet criteria for IRF admission. 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 surgical repair of a hip fracture
after a fall, hypoxemia, and COVID 19 infection. 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, in an intensive rehabilitation therapy program. While the enrollee has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive 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: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a knee orthosis, modification of supracondylar prosthetic socket, custom fabricated identified with code L1860.  You asked the Plan to pre-approve a knee orthosis. You say that you had another fall and your knee is currently swollen. The Plan denied your request. The Plan says the requested item is not medically necessary.  The Plan follows Medicare rules. Medicare rules say that custom orthoses are only 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 a knee orthosis. Our reviewer says that the documentation does not support that the requested knee orthosis is medically reasonable or necessary. Our physician reviewer found you have painful arthritis of your knees. The documentation does not document knee instability which would meet criteria for the knee orthosis or why a custom fabricated orthosis instead of a prefabricated orthosis is necessary. Therefore, you do not meet criteria for the requested custom fabricated orthosis.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a knee orthosis have not been met. Therefore, we decided that the Plan does not have to pre-approve a knee orthosis, modification of supracondylar prosthetic socket, custom fabricated identified with code L1860.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ferumoxytol injection services.
You asked the Plan to pre-approve Ferumoxytol injection services. You say that the records provided support the need for the injection services requested. The Plan denied your request. The Plan says the enrollee does not have evidence of iron deficiency and there is no reason to administer IV iron. The Plan says that the requested injection 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 Ferumoxytol injection services. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found there is no documentation that the Ferumoxytol meets Medicare criteria for medically reasonable and necessary for the enrollee. Provided laboratory reports from December 29, 2021, document a normal transferrin saturation of 20% and a normal ferritin level of 71ng/mL which are not consistent with iron deficiency to meet criteria for the requested treatment. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Ferumoxytol injection services have not been met. Therefore, we decided that the Plan does not have to pre-approve Ferumoxytol injection services.