Persius/hicric huggingface dataset:
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for Botox for the enrollee.

You asked the Plan to pre-approve Botox. You say that Botox is medically necessary for the enrollee. The Plan
denied your request. The Plan says the required step therapy criteria are not met. Maximus overturned the Plans
denial stating the step therapy requirements are not clear. The Plan requested a reopen and provided
clarification of the contracts step therapy information.

Our Medical Director looked at the case file and the reopen request. At issue is coverage for Botox.
The enrollee has a diagnosis of Spasmodic torticollis. The enrollee received botulinum injections in November
2019, and it is documented that they were not particularly effective. A repeat trial of botulinum toxin injections
was recommended. The Plan requires a trial of drug Xeomin before they will approve the requested drug. The
medical records do not show trial and failure of Xeomin. The documentation does not support that Xeomin
would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. Step
therapy may only be applied to new prescriptions or administrations of Part B drugs for enrollees that are not
actively receiving the affected medication. It is not documented that the enrollee is actively receiving Botox 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 Botox have not been met. Therefore, we decided that the Plan does not have to
pre-approve Botox for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Cyramza (ramucirumab) as monotherapy.
You asked the Plan to pre-approve the use of Cyramza. You say that it is felt this should be tried as the enrollee has limited treatment options. The Plan denied your request. The Plan says this is not covered for use as a single agent.
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 use of Cyramza. Our reviewer says that the requested drug is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is a female with stage IV colon cancer, diagnosed in 2014. She was previously treated with folinic acid/fluorouracil/oxaliplatin (FOLFOX) and recently folinic acid/fluorouracil/irinotecan (FOLFIRI) with Avastin on which she had progression of disease. Cyramza is now requested for monotherapy.
This drug is not FDA-approved for the enrollee's condition. Use in this circumstance is also not supported in the major drug compendia or CMS-approved medical journals. 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 use of Cyramza have not been met. Therefore, we decided that the Plan does not have to pre-approve Cyramza (ramucirumab) as monotherapy.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that the enrollee meets Medicare criteria for LTACH care. The Plan denied your request. The Plan says the enrollee is not stable for transfer.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving 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 the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency department visit coded 99284 provided on February 21, 2021.

You asked the Plan to pay for the emergency department visit. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.

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, we have confirmed that code 99284 for the emergency department visit has a bundled relationship with code 99285 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the emergency department visit coded 99284 provided on February 21, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the needle electromyography services coded 95872 provided on February 7, 2020.
You asked the Plan to pay for the needle electromyography services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.
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 95872 is needle electromyography using single fiber electrode, with quantitative measurement of jitter, blocking and/or fiber density, any/all sites of each muscle studied.
We find that CPT code 95872 is not supported in the medical record. Specifically, the documentation does not include documentation to support that needle electromyography using single fiber electrode, with quantitative measurement of jitter, blocking and/or fiber density, any/all sites of each muscle studied was performed. Based on this information, we decided that Medicare rules for coverage of the needle electromyography services have not been met. Therefore, we decided that the Plan does not have to pay for the needle electromyography services coded 95872 provided on February 7, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aranesp.

You asked the Plan to pre-approve Aranesp. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

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 Aranesp. Our reviewer says that the medication is not medically necessary. Our physician reviewer found there is no clinical rationale for the request. The documentation does not support that the Aranesp is medically reasonable and necessary for the enrollee. The documentation does not support that the Aranesp is safe and effective 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 Aranesp have not been met. Therefore, we decided that the Plan does not have to pre-approve Aranesp.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).

You asked the Plan to pre-approve admission to a SNF. You say that the requested admission to a SNF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF admission.

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 admission to a SNF. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the member has stabilized medically and is ready for discharge from the hospital. The member does not require skilled nursing and/or skilled therapy services on a daily basis. She is medically stable and can receive further rehab services at a lower level of care. Although further rehab services would be appropriate to improve function, as a practical matter, the intermittent skilled services can be provided at a lower level of care than a skilled nursing facility.

The member does not have any parental medication; complex wound care or nutrition given via a feeding tube. She is medically stable without any acute exacerbations of chronic medical problems. Her physical function is at or near her baseline and she can receive services at a lower level of care. Admission to a SNF for inpatient skilled rehab services 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 admission to a SNF have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.

You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. The Plan denied your request. The Plan says that all services that would be provided in the LTACH are being provided already in the current acute care setting.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
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 pneumonia and non-surgical management of an ankle fracture after a fall. Medical conditions 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. The enrollee does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of 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 service
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-sharing for an inpatient hospital stay provided from November 30, 2020, to December 3, 2020.

You asked the Plan to waive the cost-sharing for inpatient hospital stay. You say that your $150 deductible was already satisfied, and you thought your out-of-pocket maximum was also already satisfied. The Plan denied your request. The Plan says the cost-sharing amounts you are being charged are correct.

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 $250 deductible and 10% coinsurance for inpatient hospital stay. Although you may have already met the Plan's $150 general deductible, this separate $250 deductible for inpatient hospital care applies. At the time this claim was processed, $1,947.21 of the $3,000 maximum out-of-pocket amount had been met. The allowed amount of the claim is $5,402.56, resulting in a deductible amount of $250 which meets the $250 inpatient hospital care deductible. The remaining allowed amount of the claim is $5,152.56, resulting in a coinsurance amount of $515.26. Your total cost-sharing amount is therefore $765.26.

You have been asked to pay $250 deductible and 10% coinsurance for inpatient hospital stay. Inpatient hospital stay falls within the Inpatient Hospital Care 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 cost-sharing for an inpatient hospital stay provided from November 30, 2020, to December 3, 2020.
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 a heart attack and was transferred to skilled nursing on 7/23/21. Medical conditions 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. The enrollee does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy to be provided by an OON provider.

You asked the Plan to pre-approve physical therapy to be provided by an OON provider. You say that the services are necessary. The Plan denied your request. The Plan says there are in-network providers that are able to provide these services. Therefore, coverage criteria have not been met.

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 physical therapy to be provided by an OON provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve chemotherapy to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve chemotherapy. You say that you feel you will have a higher level of care at the requested facility. The Plan denied your request. The Plan says the requested services can be provided by a network provider.

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 chemotherapy 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 continuous glucose monitor (CGM) (K0554).

You asked the Plan to pre-approve a CGM. You say that the item is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet the criteria for this item.

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. Based on this information, we decided that Medicare rules for coverage of a CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) (K0554).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a brand specific power operated vehicle.

You asked the Plan to pre-approve a brand specific power operated vehicle. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 

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 brand specific power operated vehicle. Our reviewer says that the services are not medically necessary. Our physician reviewer found you have a personal mobility deficit, but the documentation does not reveal that it significantly impairs participation in MRADLs in the home and is unable to be helped by a walker or manual wheelchair.

The documentation does not reveal a home evaluation that indicates this device can be safely maneuvered in the home and that it will significantly improve MRADLs in the home. 

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 brand specific power operated vehicle have not been met. Therefore, we decided that the Plan does not have to pre-approve a brand specific power operated vehicle.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve knee orthosis (L1852).
You asked the Plan to pre-approve the orthosis. You say that you feel that knee bracing is recommended and medically necessary for the enrollee's condition due to instability and discomfort from her knee problem. The Plan denied your request. The Plan says the enrollee did not meet the medically necessary criteria.
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 orthosis. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found She is not a surgical candidate andis healing from a foot/ankle surgery. Upon review of the provided records there was insufficient evidence of the patient having had a recent surgery, directly examined joint laxity, or that there was a documented injury which might warrant a knee brace to help justify this request. Therefore, this patient does not meet LCD Medicare criteria for the knee brace 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 the orthosis have not been met. Therefore, we decided that the Plan does not have to pre-approve knee orthosis (L1852).