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

We decided that the Plandoes not haveto pre-approveTecentriq and Avastin for the enrollee.You asked the Planto pre-approvethe drugs. You say that this is medically necessary.The Plandenied your request. The Plansaysmedical studies have not proven that these drugs are helpful for the enrollee's health problem.The Plan must follow Medicare rules. The rules say that Medicare paysfor 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 therequest to pre-approve the drugs. Our reviewer says that the requested drugs are not medically reasonable or necessary. Our physician reviewer found the combination of atezolizumab and bevacizumab is not an FDA approved combination for patients with pretreated metastatic hepatocellular carcinoma. Studies have been in untreated patients and this patient is heavily pre-treated. It is not supported by major drug compendia or the NCCN guidelines at this point.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 drugs have not been met.Therefore, we decided that the Plandoes not haveto pre-approveTecentriq and Avastin for the enrollee.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Beovu (J0179).You asked the Plan to pre-approve Beovu. You say that this is medically necessary.The Plan denied your request. The Plan says the enrollee has not tried bevacizumab as required by step therapy rules.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 Beovu. Our reviewer says that the criteria for coverage of Beovu have not been met. Our physician reviewer found the Plan requires a trial of bevacizumab before they will approve the requested drug. he documentation does not state that the enrollee has tried Bevacizumab or that Bevacizumab 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 Beovu have not been met.Therefore, we decided that the Plan does not have to pre-approveBeovu (J0179).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services rendered on July 25, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says screening tests are not covered.The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes.Therefore, we decided that the Plan does not have to pay forthe laboratory services rendered on July 25, 2019.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve autologous serum eye drops.
You asked the Plan to pre-approve autologous serum eye drops. You say that the eye drops are necessary. The Plan denied your request. The Plan says that the treatment requested is not FDA approved. Therefore, coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 autologous serum eye drops. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found in your case, clinical history supports continued use of the serum tears. The records and statements state that you have failed all reasonable previous treatments for your dry eyes including artificial tear drops, Restasis, and ointments. The most effective treatment thus far has been the serum tears which is relatively low cost, very effective for you, and has been well tolerated. The autologous serum eye drops are medically reasonable and necessary considering the clinical situation. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of autologous serum eye drops have been met. Therefore, we decided that the Plan has to pre-approve autologous serum eye drops.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and appliance (E0667).
You asked the Plan to pre-approve a pneumatic compression device and appliance. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are neither emergent nor urgent to seek out-of-network care. The Plan says the enrollee furthermore does not meet criteria for the requested advanced pump.
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required. Medicare rules also 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. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. Furthermore, the requested provider is out-of-network with the Plan. The Plan states they have in-network providers available to the enrollee that can provide the items if Medicare criteria were met. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and appliance (E0667).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) admission.You asked the Planto pre-approve the SNF admission. You say that the enrollee would benefit from physical therapy in order to maximize mobility and balance at home.The Plan denied your request. The Plan says the Medicare criteria for SNF level of coverage were not met.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing and skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis and 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 SNF admission have not been met.Therefore, we decided that the Plan does not have to pre-approvethe skilled nursing facility (SNF) admission
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to provider for tertiary care.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 the tertiary level of care is not medically necessary.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the tertiary level of care is not medically necessary. Our physician reviewer found you have aortic stenosis and multi vessel coronary artery disease. You have well preserved left ventricular function and no major comorbidities that would put you at a particularly higher risk for cardiac surgery and might necessitate referral to a tertiary center for specialized monitoring or availability of tertiary type cardiac care. Based on the current clinical situation, referral to a tertiary center for cardiac surgical evaluation and management is not medically necessary and this care can be provided by the contracted community network providers.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 not been met.Therefore, we decided that the Plan does not have to pre-approve a referral to provider for tertiary care.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services provided to the enrollee on April 22, 2019.You asked the Plan to pay for the enrollee. You say that this should be paid for.The Plan denied your request. The Plan says the documentation submitted did not include a valid physician order/lab requisition or medical records (signed by the ordering physician); therefore the billed codes cannot be verified.The Plan must follow Medicare rules. Medicare rules say that a physician order must be present for labs to be covered. The documentation submitted did not include a physician order/lab requisition or medical records stating exactly tests were to be performed. Based on this information, we decided that Medicare rules for coverage of the enrollee have not been met.Therefore, we decided that the Plan does not have to pay for drug testing services provided to the enrollee on April 22, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (code D2751) for tooth #14.You asked the Plan to pre-approvethe crown. You say that the service you received in September for tooth #14 did not even last 4 months and broke off.The Plan denied your request. The Plan says this service exceeds the benefit allowance.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, crowns (one of D2740, D2750, D2751, D2752, D2790, D2791, D2792) are limited to once per tooth per 60 months. The record shows that you received a crown (code D2740) on September 24, 2019 on tooth #14, and your crowns benefit for tooth #14 is now exhausted.Therefore, we decided that the Plan does not have to pre-approvea crown (code D2751) for tooth #14.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance fora surgery received on November 2, 2018.You asked the Plan to waive the coinsurance forthe surgery. You say that you would like to be reimbursed.The Plan denied your request. The Plan says the coinsurance is your responsibility.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 30% coinsurance for out-of-network services. You have been asked to pay 30% coinsurance for the surgery. The surgery falls within the out-of-network 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 coinsurance fora surgery received on November 2, 2018.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy rendered to the enrollee from January 7, 2019 to February 22, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that that home infusion services and supplies may be covered as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The Plan does not include a mandatory supplemental benefit for home infusion therapy services or supplies. We looked at the file and Medicare and the Plan's rules. Based on this information, we decided that Medicare and the Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion therapy rendered to the enrollee from January 7, 2019 to February 22, 2019.
Benefits for these services 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care (99307) provided on August 3, 2019 by an out of network (OON) provider.You asked the Plan to pay for subsequent nursing facility care. You say that the services were necessary and should be approved.The Plan denied your request. The Plan says physician is a non-network provider who does not work with the member's health plan and the member was referred by her non-participating nursing facility. The member's primary care physician (PCP) did not refer for services. The health plan requires utilization of network providers when possible and available and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.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 pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.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. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay for subsequent nursing facility care (99307) provided on August 3, 2019 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay fortrain of four testing (CPT 95999) provided to the enrollee on January 23, 2019.You asked the Plan to pay forthe testing. You say that this should be paid for.The Plan denied your request. The Plan says the denied code is not separately billable.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 95999 is "unlisted neurological or neuromuscular diagnostic procedure."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 for the testing. Our reviewer says that the services at issue in this case were not coded correctly. Our physician reviewer found train of four monitoring is not separately billable.We looked at this physician's review, the file, and Medicare rules. Based on this information, wedecided that Medicare rules for coverage of the testing have not been met.Therefore, we decided that the Plan does not have to pay fortrain of four testing (CPT 95999) provided to the enrollee on January 23, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Rytary 95mg capsule medication.You asked the Plan to pre-approve this medication. You say that you are requesting a reconsideration of the Plan's denial as the member has tried other medications that were not effective for her condition.The Plan denied your request. The Plan says this medication is not a covered benefit under the member's contractual policy.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drug requested here is not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pre-approve the Rytary 95mg capsule medication.Benefits for this medication 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-approveEpoetin Alfa.You asked the Plan to pre-approveEpoetin Alfa. You say that this is supposed to help your hemoglobin and muscles.The Plan denied your request. The Plan says that this 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 Epoetin Alfa. Our reviewer says that Epoetin Alfa is not medically reasonable and necessary in this case. You have renal insufficiency with a hemoglobin of 12 documented. This is a normal hemoglobin and Epoetin Alfa is not indicated until hemoglobin is less than 10. Our physician reviewer found that your condition does not meet criteria for Epoetin Alfa.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Epoetin Alfa have not been met.Therefore, we decided that the Plan does not have to pre-approveEpoetin Alfa.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not haveto pay for drug testing services provided to the enrollee on March 7, 2019.You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The Plansaysthe place of service on the CMS-1500 form line 24B must reflect the location of the patient when the specimen was obtained.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.We find that CPT code 80307 and HCPCS G0482 is not supported in the medical record. Specifically, the place of service on the CMS-1500 form must reflect the location of the patient when the specimen was obtained. The claim reflects a place of service (POS) for a laboratory (POS 81), while the records reflect of place of service of a doctor's office (POS 11). Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plandoes not haveto pay fordrug testing services provided to the enrollee on March 7, 2019.
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 is immobile, unable to walk and needs assistance with everything. The Plan denied your request. The Plan says 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 above. 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 records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a SNF level of care. Ongoing pain medication and other medication management, wound/skin care, and daily therapy can be provided at a SNF. In this case, the enrollee is mostly total to maximum assist for functional transfers and activities of daily living and a less intensive, longer duration of therapy may be more appropriate. It is not clear the member would be able to fully benefit and/or participate in an IRF 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Repatha for the enrollee.
You asked the Plan to pre-approve Repatha. You say that the enrollee needs this to keep his LDL stabilized. The Plan denied your request. The Plan says that this is not covered by the enrollee's Medicare Part B 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 Repatha for the enrollee.
Benefits for Repatha may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.