Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter. 
 
You asked the Plan to pre-approve a power scooter. The Plan denied your request. The Plan says the records do 
not show that the enrollee is unable to use a lesser device such as a manual wheelchair or walker. 
 
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 power scooter. Our physician 
reviewer found that you have chronic and ongoing bilateral leg edema and weeping, chronic back pain, 
unsteady gait, history of hip replacement with weakness, and internal rotation of the hip. You have a personal 
mobility deficit, but it is not clear that this impairs participation in MRADLs in the home. Your documentation 
does not reveal the deficit is unable to be helped by the use of a walker, cane, manual wheelchair or that you 
can safely operate the requested device. Therefore, the requested scooter 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 a power scooter have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a power scooter.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Granix (J1447).
You asked the Plan to pre-approve Granix. You say that the medication is 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 Granix. Our reviewer says that the medication is not medically necessary. Our physician reviewer found the enrollee is noted to have pancytopenia attributed to splenomegaly, which is attributed to cirrhosis. There is no evidence that the enrollee has acute myeloid leukemia (AML) or a non-myeloid malignancy, or that she is receiving or is to receive chemotherapy. As such, the requested drug is not shown to be medically necessary 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 Granix have not been met. Therefore, we decided that the Plan does not have to pre-approve Granix (J1447).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group two power wheelchair.
You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied your request. The Plan says there is no physician order for this device, and the necessary evaluations have not been undergone.
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 the wheelchair. Our reviewer says that the requested wheelchair is not medically reasonable or necessary. Our physician reviewer found you have a personal mobility deficit, but it is not clear that it impairs participation in MRADLs or that the mobility deficit is unable to be helped by a manual wheelchair. The documentation does not reveal a home assessment or indication that you can safely operate the wheelchair. You do not meet the criteria for this wheelchair. 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 wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve a group two power wheelchair.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee would benefit from continued monitoring at a long-term acute hospital. The Plan denied your request. The Plan says the requested services are not medically necessary.
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 that are not currently available at the acute care hospital. Our reviewer says that the enrollee can remain at the current acute care hospital until acute services are no longer required then transferred to a lower 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 the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Carboplatin (J9045), Gemcitabine Hcl (J9201), 
Dexamethasone sodium phosphate (J1100), Palonosetron Hcl (J2469), and Aprepitant (J0185). 
 
You asked the Plan to pre-approve Carboplatin, Gemcitabine Hcl, Dexamethasone sodium phosphate, 
Palonosetron Hcl, and Aprepitant. You say that the medications are necessary. The Plan denied your request. 
The Plan says they are not responsible for covered routine costs associated with clinical trials. 
 
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of 
qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as 
people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in 
Original Medicare and the plan cost-sharing for the same services. 
 
In this case, you asked the Plan to pre-approve Carboplatin, Gemcitabine Hcl, Dexamethasone sodium 
phosphate, Palonosetron Hcl, and Aprepitant as part of a clinical trial. The Plan does not cover routine costs 
associated with qualifying clinical trials. Therefore, we decided that the Plan does not have to pre-approve 
Carboplatin (J9045), Gemcitabine Hcl (J9201), Dexamethasone sodium phosphate (J1100), Palonosetron Hcl 
(J2469), and Aprepitant (J0185).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Avastin (J9035). 
 
You asked the Plan to pre-approve Avastin. You say that the medication is 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 Avastin. Our reviewer says that the 
medication is not medically necessary. Our physician reviewer found the enrollee is noted to have diabetes and 
blurred vision. A request has been made to treat the enrollee with Avastin. Avastin is not FDA approved for 
ocular treatments. There is evidence of off-label use of Avastin to treat macular edema. A recent 
ophthalmologic examination noted that the enrollee might have some macular edema, but ultimately assessed a 
diagnosis of diabetic retinopathy without macular edema. As such, the documentation does not support the off-
label use of the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Avastin have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Avastin (J9035).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for CPT code 99190 provided on April 20, 2020.
You asked the Plan to pay for CPT code 99190. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the enrollee received these services in the facility during an inpatient hospitalization and payment for these services would be included in the Part A-DRG payment to the facility. The plan states payment for these services is the responsibility of the facility.
The Plan must follow Medicare rules. Medicare does not pay any provider or supplier other than the facility or hospital for services furnished to the beneficiary while an inpatient. We looked at the file and Medicare rules. In this case, the file shows the enrollee received these services during an inpatient hospitalization. Payment for these services were included in the facility payment. Therefore, we decided that the Plan does not have to pay for CPT code 99190 provided on April 20, 2020.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for CPT code 99496 provided on January 15, 2020. 
 
You asked the Plan to pay for CPT code 99496. You say that you would like the Plan to reconsider their denial 
of payment. The Plan denied your request. The Plan says that the services are not covered as billed. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has not provided documentation showing that the place of 
service on the claim cannot be billed with CPT code 99496. Therefore, we decided that the Plan has to pay for 
CPT code 99496 provided on January 15, 2020.  
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ambulance service, basic life support, non-emergency 
transport (A0428) and ground mileage (A0425) to be provided by an out of network (OON) provider. 
 
You asked the Plan to pre-approve non-emergency transport ambulance service and ground mileage 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 has 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 
ambulance service, basic life support, non-emergency transport (A0428) and ground mileage (A0425) to be 
provided by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approve inpatient hospital admission.
You asked the Plan to pre-approve inpatient hospital admission. You say that the services are necessary. The Plan denied your request. The Plan says that medical necessity has not been established. 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 inpatient hospital admission. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found the review has determined that the inpatient hospital admission beginning 08/01/2020 in this case was medically reasonable and 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 inpatient hospital admission have been met. Therefore, we decided that the Plan has to pre-approve inpatient hospital admission.
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says care could be received in another setting.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described 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 complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's medical status does not currently require intensive physician and nursing oversight only in an IRF. The enrollee may benefit from multiple therapies such as physical and occupational therapy but the documentation does not support that the enrollee's functional status or activity tolerance requires an 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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda and Alimta.
You asked the Plan to pre-approve the requested drugs. You say that the regimen is an approved first line treatment for the enrollee's disease. The Plan denied your request. The Plan says it is not known if the cancer is negative for EGFR and ALK mutations.
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 requested drugs. Our physician reviewer found that the drugs at issue have been requested to treat metastatic non-small cell lung cancer (NSCLC) as first line therapy. The documentation indicates that Foundation One testing, which will include molecular testing such as EGFR and ALK and others, has been ordered. It is indicated that the results will take weeks, and the enrollee needs treatment stat due to the state of the disease. The office visit notes submitted indicate that the enrollee's pain is under control and is mainly due to incision pain from his hip pinning. No other symptoms are reported such as weight loss or rapid decline. The requested use is not FDA approved for the requested use. The requested use is not supported in any of the CMS approved compendia. The use is not specifically listed as not recommended, not supported or not indicated in any of the compendia. The NCCN Guidelines emphasize that clinicians should obtain molecular testing results before administering immunotherapy if clinically feasible. The documentation has not adequately stated why the enrollee cannot wait for the pending results before receiving treatment. Therefore, the requested drugs are not 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 the requested drugs have not been met. Therefore, we decided that the Plan does not have to pre-approve Keytruda and Alimta.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for the infusion provided on March 31, 2020. 
 
You asked the Plan to reduce the coinsurance for the infusion. You say that you had this same procedure last 
year and only paid a $123 for it. You say you cannot afford this bill. 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 20% 
coinsurance for chemotherapy drugs, infusion drugs, and all other drugs covered under Medicare Part B.  
 
You have been asked to pay $1,132.96 which is 20% of the allowed amount for the infusion. The allowed 
amount is $5,664.82. ($5,664.82 x 20% = $1,132.96). The infusion falls within the Medicare Part B 
prescription drugs 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 reduce the coinsurance for the infusion provided on March 31, 2020. 
  
Our decision is only about the March 31, 2020 service. If you have any questions about prior years billing, 
please contact the plan directly.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit (99204) to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve an office visit 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 this service. Therefore, coverage criteria has 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 an office visit (99204) to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the coinsurance for injections provided by a participating provider on 
September 4, 2019 to September 30, 2019. 
 
You asked the Plan to waive the coinsurance for injections. You say that you already met your maximum out-
of-pocket amount. The Plan denied your request. The Plan says that the correct coinsurance has been applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that enrollees must pay a 20% coinsurance with a $3,400 max out-of-pocket amount 
for Medicare Part B prescription drugs.  
 
The Plan says you must pay a 20% coinsurance for injections. Based on the Plan contract, however, you cannot 
be asked to pay more than $3,400 max out-of-pocket amount. Therefore, we decided that the Plan has to waive 
the coinsurance for injections provided by a participating provider on September 4, 2019 to September 30, 
2019.  
 
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 shower chair. 
 
You asked the Plan to pre-approve a shower chair. You say that the requested item is necessary. The Plan 
denied your request. The Plan says the item is not primarily medical in nature. Therefore, coverage criteria has 
not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.