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

We decided that the Plan does not have to pre-approve Keytruda.
You asked the Plan to pre-approve Keytruda. You say that the requested Keytruda is medically necessary. The Plan denied your request. The Plan says the requested Keytruda is not medically necessary.
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 Keytruda. Our reviewer says that the requested Keytruda is not medically necessary. Our physician reviewer found Keytruda is FDA approved for the treatment of recurrent locally advanced or metastatic squamous cell carcinoma of the esophagus in patients whose tumors express PD-L1 (CPS greater than or equal to 10) as determined by an approved test, with disease progression after one or more prior lines of systemic therapy. In addition, this enrollee has not had prior therapy. The use is listed as not indicated, not supported or not recommended by NCCN Guidelines in patients with poor performance status (ECOG 3-4) and the enrollee is ECOG 3. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have to pre-approve Keytruda.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive or reduce the copayment for the tangential biopsy of a skin lesion (11102) and the outpatient clinic visit (G0463) provided on September 22, 2020.
You asked the Plan to waive or reduce the copayment for the biopsy and clinic visit. You say that you feel the price is too high for the service provided. The Plan denied your request. The Plan says the copayment was applied correctly for the services billed.
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 $385 copayment for outpatient surgery, including but not limited to hospital or other facility charges. You have been asked to pay a $318.39 copayment for the biopsy and clinic visit. The biopsy and clinic visit fall within the outpatient surgery benefit category, which includes hospital or other facility charges. 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 or reduce the copayment for the tangential biopsy of a skin lesion (11102) and the outpatient clinic visit (G0463) provided on September 22, 2020.
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 this enrollee does not require transfer to a SNF. He does not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse required to safely and effectively provide medically necessary and reasonable treatment in a SNF. The enrollee has no complex wound care or other skilled nursing need. The enrollee's functional level 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 only in a SNF. Skilled nursing or therapy services are not required on a daily basis or as a practical matter on an inpatient basis, in a skilled nursing facility setting. The enrollee's needs are currently being met in the IRF and there are no extenuating factors that would require a transfer to a SNF. The enrollee can continue care in the IRF to prepare for a safe discharge to home or a community-based environment as recommended by Medicare guidelines. 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an injection provided by a participating provider on January 16, 2020.
You asked the Plan to waive the coinsurance for an injection. You say that your out-of-pocket maximum has been met and you are still trying to get this bill taken care of. The Plan denied your request. The Plan says the correct coinsurance has been applied.
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 20% coinsurance for Medicare Part B prescription drugs. You have been asked to pay less than a 20% coinsurance of the allowed amount for an injection. The total allowed amount is $,488.88. You are 20% coinsurance is $883.52 ($4,417.60 x 20% = $883.52). You are being asked to pay is $615.48. An injection 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 waive the coinsurance for an injection provided by a participating provider on January 16, 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 service is medically necessary. The Plan denied
your request. The Plan says you can safely receive the services you need in a lower 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 in the Medicare rules section.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found there are no complex nursing or rehabilitation needs and there is no documented need
for intensive rehabilitation 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 IRF care have not been met. Specifically, you can obtain services in a lower
level of care. This means admission to an IRF is not medically necessary. 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 the Vascepa 1gm capsule medication.

You asked the Plan to pre-approve this medication. You say that this medication is medically necessary for the enrollee. The Plan denied your request. The Plan says this medication is not a covered benefit under the enrollee'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 Vascepa 1gm 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the enrollee does not meet criteria for IRF admission. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for surgical repair of a hip fracture after a fall. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, in an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Omeprazole cap 20mg for the enrollee.

You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your
request. The Plan says this medication was denied due to benefit exclusion.

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 Omeprazole cap 20mg for
the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an injection provided by a participating
provider on January 2, 2020.
You asked the Plan to waive the coinsurance for an injection. You say that your maximum out-of-pocket
expense has already been met. The Plan denied your request. The Plan says the correct coinsurance has been
applied.
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 20%
coinsurance for Medicare Part B prescription drugs.
You have been asked to pay a 20% coinsurance of the allowed amount for an injection. The total allowed
amount is $4,417.60. The total amount you are being asked to pay is $883.52 ($4,417.60 x 20% = $883.52).
Your max out-of-pocket amount was not met at the time of these services; therefore, the correct coinsurance
has been applied. An injection 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 waive the coinsurance for an injection provided by a participating provider on January 2,
2020.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve use of onabotulinumtoxin-A (Botox).
You asked the Plan to pre-approve Botox. You say that you feel this is necessary. The Plan denied your request. The Plan says that the denial of authorization for this drug is correct, because the requested use is cosmetic in nature.
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 Botox. Our reviewer says that the enrollee meets the Medicare criteria for use of Botox. Our physician reviewer found the requested use of onabotulinumtoxin-A is not Food & Drug Administration (FDA) approved for the enrollee's diagnosis. However, this use of the drug is supported by major drug compendia, specifically the Drugdex/Micromedex and The American Hospital Formulary Service Drug Information compendia both indicate a clinical benefit of onabotulinumtoxin-A for hemifacial spasms of various etiologies. Based on the records provided there is documentation that the requested drug is safe and effective and otherwise reasonable and necessary 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 Botox have been met. Therefore, we decided that the Plan has to pre-approve use of onabotulinumtoxin-A (Botox).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ultrasounds provided by a participating
provider on September 29, 2020.
You asked the Plan to waive the copayment for ultrasounds. You say that you went for your annual wellness
exam. You say that you shouldn't have to pay for this. The Plan denied your request. The Plan says the correct
copayment has been applied.
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 $20
copayment for outpatient diagnostic tests/ultrasounds.
You have been asked to pay a $20 copayment for each ultrasound. The total amount you are being asked to pay
is $40 ($20 x 2 ultrasounds = $40). When additional services are provided during an annual wellness exam,
additional copayments are applied. An ultrasound falls within the outpatient diagnostic tests/ultrasounds 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 copayment for ultrasounds provided by a participating
provider on September 29, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation mileage.
You asked the Plan to pre-approve the additional mileage. You say that this is required to get to medical appointments. The Plan denied your request. The Plan says the service is a covered benefit, but the request exceeds the mileage limit.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The plan covers routine transportation up to 75 miles one-way. You are requesting more mileage than the benefit offers. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation mileage.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy provided by an out-of-network provider on October 5, 2020.
You asked the Plan to pay for physical therapy. You say that your office and providers are participating providers with Medicare and the enrollee is entitled to all Medicare approved services. You say that the services were medically necessary and should be approved for payment. The Plan denied your request. The Plan says authorization was required but 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 had network providers available who could have provided 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 physical therapy provided by an out-of-network provider on October 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the consultation (D9310) with the periodontist provided on October 2, 2020.
You asked the Plan to pay for the dental service. You say that you are not able to get a filling cap or crown without seeing the periodontist prior. The Plan denied your request. The Plan says consultation is not listed as a covered service.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the consultation (D9310) with the periodontist provided on October 2, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keppra tab 500mg for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says this is denied as a benefit exclusion.
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 Keppra tab 500mg for the enrollee.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve use of Zarxio (filgrastim).

You asked the Plan to pre-approve Zarxio. You say that this is needed to prevent negative outcomes associated with chemotherapy. The Plan denied your request. The Plan says that the denial of authorization for Zarxio is correct, because the enrollee has little risk for fever and low white blood cell counts.

The Plan follows Medicare rules. Medicare rules state that filgrastim (such as Zarxio) may be covered for FDA-approved labeled indications or other certain indications described in the previous 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 Zarxio. Our reviewer says that the enrollee meets the Medicare criteria for the requested use of Zarxio. Our physician reviewer found single agent carboplatin carries a risk of neutropenic fever of greater than 10% and pemetrexed is slightly less. However, couples with the enrollee's age, anemia, and renal insufficiency his risk of neutropenic fever is likely greater than 20%. This makes the use of growth factors, such as Zarxio, 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 Zarxio have been met. Therefore, we decided that the Plan has to pre-approve use of Zarxio (filgrastim).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the services are medically necessary. The Plan denied your request. The Plan says services can be provided at a lower level of care.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found there are no complex nursing or rehabilitation needs and there is no documented need for intensive rehabilitation 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 IRF care have not been met. Specifically, services can be obtained at a lower level of care. This means admission to an IRF is not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the CPAP machine and accessories (E0601, E0562, A4604, and A702) to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve CPAP machine and accessories. You say that the items are medically necessary. The Plan denied your request. The Plan says your primary care doctor has referred you to a company that is able to provide you with the medically necessary equipment, and will provide you with comfort equipment that is on backorder as soon as they are available.

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 the CPAP machine and accessories (E0601, E0562, A4604, and A702) to be provided by an out of network (OON) provider..