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

We decided that the Plan has to pre-approve Iluvien (J7313).
You asked the Plan to pre-approve Iluvien. You say that the enrollee needs Iluvien approved because it is more effective than other drugs. The Plan denied your request. The Plan says that the drug, Iluvien, is not being prescribed for a medically-accepted indication.
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 Iluvien. Our reviewer says that treatment with Iluvien in this case is medically necessary and meets coverage criteria based on the medical records and the available medical evidence. Our physician reviewer found in this case, the enrollee is treated for refractory diabetic macular edema that has persisted in spite of more common intravitreal treatments (Aflibercept and Bevacizumab). Iluvien carries a contraindication in patients with high cup/disc ratio (>0.8) because it is an indicator for glaucoma, and intravitreal steroids can cause elevation of intraocular pressure in some cases. Our reviewer found that study protocols for intravitreal flucinolone excluded patients with cup/disc > 0.8 because it is a potential indicator for poorly controlled or severe glaucoma. The labeled contraindication is a reflection of that. The Plan's argument that prior steroid treatment is required before use of Iluvien, however, is not valid. Our physician reviewer also found that in spite of the Food and Drug Administration (FDA) labeled contraindication for cupping, there is no medical reason to withhold this drug from a patient with no history of poorly controlled glaucoma, especially in a case like this where the patient has demonstrated no increase in pressure after other intravitreal steroid treatments. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Iluvien have been met. Therefore, we decided that the Plan has to pre-approve Iluvien (J7313).
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 medical services provided on June 9, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the home visit. You say that the service was medically necessary. The Plan denied your request. The Plan says no prior authorization was 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 the medical services provided on June 9, 2020 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the corneal transplant provided on August
31, 2020.
You asked the Plan to waive the copayment for the corneal transplant. You say that your claim was denied and
do not know why you should have to pay the $250 copayment. The Plan denied your request. The Plan says the
claim was reprocessed, and 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 $250
copayment for each in-network Medicare-covered outpatient surgery at an ambulatory surgical center or
outpatient hospital.
You have been asked to pay a $250 copayment for the corneal transplant. The corneal transplant falls within
the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical
centers" 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 the corneal transplant
provided on August 31, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0676) provided on
September 4, 2020.
You asked the Plan to pay for a pneumatic compression device. You say that the requested item is medically
necessary for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met.
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the
purpose of prevention of venous thromboembolism (E0676) is a preventive service.
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, this item is not a covered benefit of Medicare or the Plan.
This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided
that the Plan does not have to pay for a pneumatic compression device (E0676) provided on September 4,
2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental services (dental codes D0350, D1999, D4341, D1330, D4921, and D4999) provided on October 13, 2020.
You asked the Plan to pay for dental services. You say that you believe this dental practice is scamming you and these charges are not right. The Plan denied your request. The Plan says the cost-sharing amounts you are being charged are correct, and the denial of payment for non-covered dental services is also correct.
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. The Plan covers dental code D4341 with 50% coinsurance for the enrollee. The total allowed amount of this code is $568, resulting in a total coinsurance of $284. The amounts of the non-covered dental services total $1,499. Your total responsibility for this claim is therefore $1,783. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services have dental cost-sharing that you are responsible for or are not covered by this benefit. Therefore, we decided that the Plan does not have to pay for dental services (dental codes D0350, D1999, D4341, D1330, D4921, and D4999) provided on October 13, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa.
You asked the Plan to pre-approve Euflexxa. The Plan denied your request. The Plan says this is not covered when provided by a pharmacy.
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be brought to the office for administration. Since the medication does not represent an expense to the physician and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that the Plan does not have to pre-approve Euflexxa.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the treatment of a root canal obstruction (D3331) and the root canal (D3330) provided on September 11, 2019.
You asked the Plan to pay for the dental services. You say that the services should be covered. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan also says that dental services that you receive out of network are not covered.
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, dental services that you receive out of network are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the treatment of a root canal obstruction (D3331) and the root canal (D3330) provided on September 11, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital care provided from September 7, 2018, to
September 8, 2018.
You asked the Plan to pay for the inpatient hospital care. You say that the claim was properly billed. The Plan
denied your request. The Plan says DRG 303 is more appropriate than the DRG billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report inpatient hospital services with the appropriate DRG. DRG 281 is defined as Acute
Myocardial Infarction, Discharged Alive with Complication or Comorbidity.
In this case, you billed the services provided from September 7, 2018, to September 8, 2018, with DRG 281.
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 inpatient hospital care. Our reviewer
says that DRG 281 is not supported by the records. Our physician reviewer found while a mild elevation of
troponin was noted, this was not a significant elevation. In addition, the EKG did not show new evidence of
ischemia. The cardiologist also indicated that the patient's symptoms were consistent with angina.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the
medical records do not substantiate DRG 281. Therefore, we decided that the Plan does not have to pay for
inpatient hospital care provided from September 7, 2018, to September 8, 2018.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.

You asked the Plan to pre-approve these services. You say that the enrollee needs more therapy and surgical aftercare. The Plan denied your request. The Plan says the admission is not medically necessary.

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 these services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to an inpatient rehabilitation facility (IRF) after hospitalization for a broken left hip and surgical repair. He received oral medications and had stable vital signs. He received physical and occupational therapy in the hospital and needs minimal to maximal assistance with bed mobility and transfers. He is non-ambulatory with a lower left extremity weight bearing restriction. He has no skilled nursing needs. He has skilled therapy needs but does not require skilled therapy on a daily basis. As a practical matter, the enrollee does not require the necessary services on an inpatient basis at the SNF 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the acupuncture services.

You asked the Plan to pay for these services. You say that you called the Plan prior to the visits to ensure the services were covered. The Plan denied your request. The Plan says the services are not covered.

The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year.

We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Specifically, the file shows that you did not receive acupuncture for the treatment of chronic low back pain. Therefore, we decided that the Plan does not have to pay for the acupuncture services.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on February 27, 2020 to April 15, 2020 by a non-participating provider.
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 were rendered by a non-participating provider without prior authorization.
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 the medical services provided on February 27, 2020 to April 15, 2020 by a non-participating provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the retroperitoneal ultrasound.

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 76775 is not separately payable.

The Plan must follow Medicare rules. Medicare rules say that a physician shall not report a separate evaluation and management code with procedures with a global surgery indicator of "XXX."

We looked at the file and Medicare rules. The file shows that code 76775 (retroperitoneal ultrasound) was billed with evaluation and management code 99285 (emergency department visit). This code has a global surgery indicator of 0 and is not appropriate to bill with an E&M code. 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 retroperitoneal ultrasound.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xiidra.

You asked the Plan to pre-approve Xiidra. The Plan denied your request. The Plan says this is not covered under the 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 Xiidra.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the palliative treatment (D9110) and the periapical x-ray (D0220) provided on October 27, 2020. You asked the Plan to pay for the dental services. You say that your gum was cut at a previous appointment in order to place a filling. You say that you have an autoimmune disease. You say that as a result, the wound did not heal, and you were in intolerable pain. You say that you had an emergency appointment to take care of it. You say also that the x-ray was necessary to determine why your gum was not healing properly. The Plan denied your request. The Plan says periapical x-ray is not listed as covered service. The Plan says that palliative treatment is not listed as a covered service either. 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 palliative treatment (D9110) and the periapical x-ray (D0220) provided on October 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis.

You asked the Plan to pay for the lumbar-sacral orthosis (L0650). You say that the orthosis was medically necessary. The Plan denied your request. The Plan says the enrollee's claim history shows that there are no claims from the ordering physician.

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 lumbar-sacral orthosis (L0650). Our reviewer says that the orthosis is not medically necessary. Our physician reviewer found the enrollee's chief complaint was chronic lower back pain. The available documentation in the case file does not support that the requested lumbar-sacral orthosis was medically reasonable and necessary for the enrollee in this case, according to the coverage criteria established by the LCD. An appropriate history and a physical examination of the back would reasonably be required to adequately assess whether the coverage criteria for an Lumbar Sacral Orthosis have been met. The documentation does not support that the lumbar-sacral orthosis was prescribed for one or more of the covered indications in this case, as there is insufficient documentation of a credible evaluation and a credible physical examination of the back.

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 lumbar-sacral orthosis (L0650) have not been met. Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on October 8, 2020.
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says that
non-emergent, non-urgent services with out-of-network providers require prior authorization.
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 did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for laboratory services provided on October 8, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the myocardial perfusion imaging and stress tests provided by an out-of-network provider on October 1, 2019.
You asked the Plan to pay for the myocardial perfusion imaging and stress tests. The Plan denied your request. The Plan says this provider is not a network provider with the Plan.
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 the myocardial perfusion imaging and stress tests provided by an out-of-network provider on October 1, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Pembrolizumab (Keytruda).
You asked the Plan to pre-approve Keytruda. You say that this medication is necessary to treat the enrollee's disease. The Plan denied your request. The Plan says the clinical value and effectiveness of Keytruda in the setting of glioblastoma have not been demonstrated in the peer-reviewed literature.
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 Pembrolizumab (Keytruda) is not medically reasonable and necessary for the enrollee. Our physician reviewer found the requested use of Keytruda is not FDA-approved for the enrollee's diagnosis. Our reviewer found that the use is not supported by one of the major drug compendia or by clinical research that appears in a Centers for Medicare & Medicaid Services approved medical journal. Early experience with checkpoint inhibitors such as Pembrolizumab and Nivolumab in patients with recurrent high-grade glioma has shown only modest activity, and use of checkpoint inhibitors in unselected patients with recurrent high-grade glioma is not recommended outside of a clinical trial. Our physician reviewer also found that the use is not listed as not indicated, not supported or not recommended in any of the compendia. 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 Pembrolizumab (Keytruda).