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

We decided that the Plan does not have to pre-approve Privigen.
You asked the Plan to pre-approve Privigen. You say that this is medically necessary. The Plan denied your request. The Plan says the requested use is not supported.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved 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 Privigen. Our reviewer says that the requested use of Privigen is not reasonable or medically necessary. Our physician reviewer found this patient with Chronic Lymphocytic Leukemia (CLL) and recurrent infections has an immunoglobulin G level of 862. For Privigen (IVIG) to be covered for bacterial infections from CLL the IgG level should be <200 with recurrent infections and documentation of a deficiency of producing antibodies to vaccination. Therefore, it is not medically reasonable and necessary at this time. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Privigen have not been met. Therefore, we decided that the Plan does not have to pre-approve Privigen.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on September 2, 2019 by an
out of network (OON) provider.
You asked the Plan to pay for outpatient services. You say that the enrollee presented for immediate care, and
there are no prior authorization requirements for these services. The Plan denied your request. The Plan says
the denial of payment for these services is correct, because this provider is out-of-network with the Plan and the
enrollee self-directed for service.
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 the medical services provided on September 2,
2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for deluxe lens feature (V2702) deluxe frames (V2020) antireflective coating (V2750) polycarbonate lens (V2784) miscellaneous vision item (V2799) vision supply/accessory (V2797) provided November 12, 2019. You asked the Plan to pay for the vision services. You say that the provider's office told you that you qualified for $175 annual discount and this is the opposite of what they told you. The Plan denied your request. The Plan says this service is not covered by the plan. Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers up to $175 for the costs of eyeglasses or contact lenses every year. The plan applied the $175 to the covered item lenses (V2781 26). You are responsible for the remaining cost of the uncovered services. We looked at the file and the Plan's rules. the plan covers for the cost of frames and lenses. Based on this information, we decided that the Plan's rules for coverage of the vision services have not been met. Therefore, we decided that the Plan does not have to pay for deluxe lens feature (V2702) deluxe frames (V2020) antireflective coating (V2750) polycarbonate lens (V2784) miscellaneous vision item (V2799) vision supply/accessory (V2797) provided November 12, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered to the enrollee on September 13, 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 procedure code 86335 is not supported. 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 86335 is immunofixation electrophoresis; other fluids with concentration (eg, urine, CSF). We find that CPT code 86335 is not supported in the medical record. Specifically, there is no documentation that immunofixation electrophoresis was performed for the enrollee on the date of service at issue. 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 pay for the laboratory services rendered to the enrollee on September 13, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services for the enrollee. You asked the Plan to pre-approveIRF care. You say that the enrollee is not able to go home.The Plan denied your request. The Plan says the services are 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 services are not medically necessary. Our physician reviewer found the enrollee was admitted to the hospital on March 8, 2020 after presenting with weakness. He was found to have acute kidney failureand was started on intravenous (IV) fluids. His kidney function has returned to normal. His current needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. He may benefit from further therapy but does not require an intensive therapy program 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-approveacute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not haveto pay forurology services provided to the enrollee on April 4, 2019.You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The Plansaysthese services were not coded correctly.The Plan must follow Medicarerules. 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 the denied codes is:CPT 54235:Injection of corpora cavernosa with pharmacologic agent(s) (eg, papaverine, phentolamineHCPCS J3490:Unclassified drugs 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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our physician reviewer found the records indicate that a penile injection was to be performed, but the records do not document that the injection was performed or by whom. Therefore, the billing of CPT 54235 and the associated J3490 is not supported.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverageof the services have not been met.Therefore, we decided that the Plandoes not haveto pay forurology services provided to the enrollee on April 4, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Invokana for the enrollee. 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 self-administered drugs are not covered. 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 Invokana for the enrollee.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on September 20, 2019 by an out of network (OON) provider.
You asked the Plan to pay for outpatient service. You say that you have been using this provider for several years and it is normally covered for you. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and prior authorization was not obtained.
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 the medical services provided on September 20, 2019 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approvePerforomist for the enrollee.You asked the Plan to pre-approvethese services. You say that you disagree with the denial.The Plan denied your request. The Plan says that the services are not medically necessary.The Plan must follow Medicare rules. Medicare rules say that 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 these services. Our reviewer says that the services are medically necessary. Our physician reviewer found the enrollee has chronic obstructive pulmonary disease (COPD) with symptoms of exertional dyspnea and documentation of airways obstruction on pulmonary function testing. She has been unable to use traditional inhalers because of difficulty coordinating actuationand inhalation. The requested nebulized long-acting beta-2 agonist (LABA) is reasonable and medically necessary at this time.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have been met.Therefore, we decided that the Plan has to pre-approvePerforomist for the enrollee. 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the dermatology services provided on August 15, 2019 by an
out of network (OON) provider.
You asked the Plan to pay for the OON services. You say that the services should be covered because of your
familiarity with the practitioner and his excellent care. The Plan denied your request. The Plan says there are
in-network providers available to meet your needs.
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 dermatology services at issue in this appeal. The Plan did not pre-approve the
services at issue. We found no exception that would require the Plan to pay for these OON services. Therefore,
we decided that the Plan does not have to pay for the dermatology services provided on August 15, 2019 by an
out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a free-standing inpatient psychiatric facility 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 the records show that the enrollee's condition has improved, and is no longer a threat to themselves or others.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 based upon a review of the records provided, the enrollee does not meet the criteria for continued acute inpatient mental health treatment for the dates in question in this case. The enrollee is not a danger to herself or others. She was not showing any auditory or visual hallucinations, and was cooperative/compliant with treatment while not showing any threats to safety. 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 free-standing inpatient psychiatric facility for the enrollee.
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 the amount, frequency, and duration of services are not reasonable, and the enrollee can be provided therapies at a lower level of care, such as three times a week.
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 admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment. The enrollee does not have a tracheostomy tube, enteral feedings, complex wound care or other SNF level skilled nursing need. This enrollee is at a functional level that does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist required to safely and effectively provide medically necessary and reasonable treatment in a SNF. The enrollee does not require these skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis". As a practical matter this enrollee does not require the necessary services on 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Siliq for the enrollee.
You asked the Plan to pre-approve Siliq. The Plan denied your request. The Plan says that this drug 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 Siliq for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveXenleta 150mg, every 12 hours for 7 daysYou asked the Planto pre-approvethe drugs. You say that this is medically necessary.The Plandenied your request. The Plansaysthe requested indication for use is not an FDA-approved indication, and is not supported by compendia review.The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the drugs. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found the enrollee is noted to have chronic sinusitis and multiple drug allergies. A request ash been made for Xenleta to treat her condition. Xenleta is FDA approved for the treatment of community acquired pneumonia. No provider records have been submitted to explain why the off-label use of Xenleta should be allowed. The requested drug is not shown to be medically necessary, indicated or reasonable.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-approveXenleta 150mg, every 12 hours for 7 days
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approveAtezolizumab (Tecentriq) for the enrollee. You asked the Plan to pre-approveTecentriq. The Plan denied your request. The Plan says that the enrollee's current therapy is not approved as a category 1 or 2 in guidelines for neuorendocrine small cell cancer.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 Tecentriq. Our physician reviewer found that the enrollee has metastatic small cell neuroendocrine cancer of bladder/rectum. This review relates to a request for Tecentriq to be used in combination with Carboplatin and Etoposide. The requested drug is not FDA approved for the requested indication. The drug is not supported in any of the CMS compendia. However, the NCCN Guidelines version 3.2020 Bladder Cancer page MS-32 state that patients with small cell carcinoma of the bladder are best treated with initial chemotherapy (see NCCN Guidelines for Small Cell Lung Cancer.) The NCCN Guidelines Version 3.2020 Small Cell Lung Cancer page SCL-E 1 of 4 lists the requested combination of Carboplatin, Etoposide and Atezolizumab as a preferred regimen for extensive stage disease, ie. metastatic. Therefore, the requested combination is medically reasonable and necessary and safe and effective.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Tecentriq have been met. Therefore, we decided that the Plan has to pre-approveAtezolizumab (Tecentriq) for the enrollee. 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveTrulicity for the enrollee. You asked the Plan topre-approveTrulicity. You say that the enrollee's blood sugar is running high.The Plan denied your request. The Plan says the enrollee's medical plan does not cover outpatient prescription drugs.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-approveTrulicity for the enrollee. Benefits for Trulicitymay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe podiatry visit provided on December 18, 2019.You asked the Plan to waive the copayment forthe podiatry visit. You say that this was a post-op visit and there should not be a copayment.The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment for each in-network Medicare-covered visit. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the $40 copayment for the podiatry visit.You have been asked to pay a $25 copayment for the podiatry visit. The podiatry visit falls within "Podiatry services" benefit category. The record shows this appointment was outside of the 10-day global period for your procedure on December 4, 2019.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 thePlan. Therefore, we decided that the Plan does not have to waive the copayment forthe podiatry visit provided on December 18, 2019.