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

We decided that the Plan does not have to pre-approve blepharoplasty.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that blepharoplasty is covered when specific criteria are met. 

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 not medically necessary. Our physician reviewer found the enrollee has dermatochalsis of bilateral upper and lower lids. The record does not include visual field testing or margin to reflex distance (MRD) value. The record indicates that the lower lid repairs are cosmetic in nature. The submitted photographs do not support medical necessity. The criteria for coverage are not met and the blepharoplasty is therefore not reasonable or 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 not been met. Therefore, we decided that the Plan does not have to pre-approve blepharoplasty.
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 services are 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 Keytruda. Our reviewer says that the medication is not medically necessary. Our physician reviewer found although pembrolizumab (Keytruda) is FDA approved for the treatment of metastatic melanoma this enrollee has toxicities related to immunotherapy with nivolumab in combination with ipilimumab. There are no published articles to support switching from one immunotherapy to another to avoid toxicity especially when both nivolumab and pembrolizumab are PD1 inhibitors. The service is not reasonable or 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 Keytruda have not been met. Therefore, we decided that the Plan does not have to pre-approve Keytruda
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for a third level of facet joint injections (64634-59) provided on
January 21, 2021.

You asked the Plan to pay for a third level of facet joint injections. You say that this is clearly indicated. The
Plan denied your request. The Plan says this is not documented.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.

We find that CPT code 64634-59 is not supported in the medical record. Specifically, the records only
document that two levels of facet joint injections were performed. Based on this information, we decided that
Medicare rules for coverage of a third level of facet joint injections have not been met. Therefore, we decided
that the Plan does not have to pay for a third level of facet joint injections (64634-59) provided on January 21,
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a home visit (99348) provided on February 20, 2021, by an
OON provider.

You asked the Plan to pay for a home visit. You say that the patient was unaware of any additional primary
care physicians at the time of service. The Plan denied your request. The Plan says services were provided by
an out-of-network 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. The records provided for review do not show that the services at issue were urgent or
emergent. The records provided for review also show that the enrollee was referred by a non-participating
provider. 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 a home visit (99348) provided on February 20, 2021, by an OON
provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional physical therapy visits for the enrollee.

You asked the Plan to pre-approve the additional visits. You say that this is medically necessary. The Plan
denied your request. The Plan says only two visits can be approved.

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient
therapy.

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 additional visits. Our reviewer says
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's
condition. Our physician reviewer found based on the medical records provided, there is no documentation that
the requested therapy is generally accepted as specific and effective therapy for the enrollee's condition. Based
on the available records, objective details of the enrollee's limitations and progress with therapy are not
provided to justify the requested physical therapy treatment sessions. Further utilization of a home exercise
program appears appropriate at this point.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the additional visits have not been met. Therefore, we decided that the Plan
does not have to pre-approve additional physical therapy visits for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa injections (J7323).

You asked the Plan to pre-approve Euflexxa. You say that Euflexxa is medically necessary. The Plan denied your request. The Plan says a trial Orthovisc, Monovisc, and Synvisc is required before alternatives like Euflexxa can be considered.

Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Euflexxa. Our reviewer says that Euflexxa is not medically necessary. Our physician reviewer found the records show no trial of the plan preferred agents, or any reason why they would be unsafe or ineffective for this 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 Euflexxa have not been met. Therefore, we decided that the Plan does not have to pre-approve Euflexxa injections (J7323).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on January 8, 2021.

You asked the Plan to waive the copayment for the office visit. You say that you were not aware you had a copayment each time you visited the doctor, and you should not have to pay. The Plan denied your request. The Plan says the copayment applied correctly.

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 $30 copayment for each in-network, Medicare-covered primary care provider visit.

You have been asked to pay a $30 copayment for the office visit. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" 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 office visit provided on January 8, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an x-ray (71045) provided on December 30, 2020.

You asked the Plan to pay for an x-ray. You say that this service is supported in the records. The Plan denied your request. The Plan says this is not separately payable.

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, we have confirmed that code 71045 has a bundled relationship with code 71046 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for an x-ray (71045) provided on December 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the eye exam (92004) provided on November 9, 2020.

You asked the Plan to reduce the copayment for the eye exam. You say that the provider who performed these services is a specialist, so you should only be expected to pay the $15 specialist office visit copayment. The Plan denied your request. The Plan says the service at issue is a diagnostic eye exam rather than an office visit. Medicare-covered diagnostic eye exams require a $25 copayment.

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 $25 copayment for Medicare-covered diagnostic eye exams. 

You have been asked to pay a $25 copayment for the eye exam. The eye exam falls within the Medicare-covered diagnostic eye exams 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 copayment for the eye exam (92004) provided on November 9, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda (J9271).

You asked the Plan to pre-approve Keytruda. You say that this request is medically necessary. The Plan denied
your request. The Plan says the coverage criteria have not been met.

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 drug is not medically reasonable and necessary. Our physician reviewer found the enrollee is a 67-
year-old female diagnosed with left side renal cell carcinoma. In this case, Keytruda is not FDA-approved for
the enrollee's condition. In addition, regarding the major drug compendia or clinical research that appears in a
CMS-approved medical journal, the use of Keytruda is still in abstract form and awaiting mature data and
regulatory approval.

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 (J9271).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy provided on January 14, 2021 by an out of
network provider.

You asked the Plan to pay for the psychotherapy (90832). You say that the physician depended upon the
hospital staff to verify eligibility and obtain authorization. The Plan denied your request. The Plan says medical
necessity could not be determined due to lack of medical documentation therefore payment is denied due to no
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 service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for the service. Therefore, we decided that the Plan does not have to pay for psychotherapy provided on January 14, 2021 by an out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a seat lift mechanism.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.

The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions listed in the Medicare rules section are met.

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 you do not meet the criteria for coverage. Our physician reviewer found the records show that you have a history of arthritis, diabetes, chronic lung disease, and Cushing's disease.

You have severe arthritis of the hip and/or knee. Although the seat lift mechanism would likely reduce the risk of falls and that you are incapable of standing from a chair in the home, the records show that you do not have the ability to ambulate once standing. The criteria for coverage are not met and the seat lift mechanism is therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a seat lift mechanism.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the transthoracic echocardiography (93350) provided on
January 22, 2021 by an out of network (OON) provider.

You asked the Plan to pay for the diagnostic services. You say that kindly reconsider the claim for processing
to remit payment due. The Plan denied your request. The Plan says enrollee's must receive their medical
services from an in-network provider with the exception being urgent or emergent services. Non-emergent
services with non-contracted providers require prior authorization before services being rendered.

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 transthoracic echocardiography (93350) provided on January 22, 2021 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytuda, Paclitaxel, Ondansetron, and Dexamethason.

You asked the Plan to pre-approve Keytuda, Paclitaxel, Ondansetron, and Dexamethason. You say that the services are 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 Keytuda, Paclitaxel, Ondansetron, and Dexamethason. Our reviewer says that the medication is not medically necessary. Our physician reviewer found the combination of paclitaxel and pembrolizumab is not FDA approved. Use is not supported by major drug compendia or the medical literature. Either as single agent is standard. The service is not reasonable or 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 Keytuda, Paclitaxel, Ondansetron, and Dexamethason have not been met. Therefore, we decided that the Plan does not have to pre-approve Keytuda, Paclitaxel, Ondansetron, and Dexamethason.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a computed tomography (CT) scan (70450) provided on
November 27, 2020.

You asked the Plan to pay for a CT scan. You say that the enrollee had multiple exams on this date. The Plan
denied your request. The Plan says this is not separately payable without a modifier.

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, we have confirmed that code 70450
has a bundled relationship with code 70496 and cannot be paid as billed. This code cannot be paid as a separate
line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided
that the Plan does not have to pay for a computed tomography (CT) scan (70450) provided on November 27,
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 SNF care. You say that you need SNF care. The Plan denied your request.
The Plan says rules for SNF care have not been reasonable and 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 SNF care. Our reviewer says that daily
skilled services are not necessary. Our physician reviewer found based on the latest medical records provided,
you are reported to be unstable for discharge from the acute hospital. Your discharge has been placed on hold
due to "worsening respiratory status, chest pain, worsening thrombocytopenia and need for bone marrow
biopsy." Since you have been reported unstable for discharge, the requested transfer to a SNF cannot be
considered 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 SNF care 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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 45 home health nurse visits.

You asked the Plan to pre-approve the home health visits.. You say that you need these services. The Plan denied your request. The Plan says the criteria for coverage has not been met.

The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.

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 45 home health nurse visits. Our reviewer says that the home health nurse visits are not medically necessary. Our physician reviewer found the provided documentation does not indicate that you require skilled nursing services to effectively provide treatment, care, and/or services in order to improve your condition, perform a maintenance program to maintain your condition and/or prevent deterioration. The reviewer found that you have been medically stable without any recent exacerbations of chronic medical problems or hospitalizations. The reviewer found that previous home health nursing services should have been sufficient for education regarding disease management. Therefore, the reviewer found that the requested home health services are 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 the home health visits. have not been met. Therefore, we decided that the Plan does not have to pre-approve 45 home health nurse visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet joint injections.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that facet injections are covered when specific criteria are met. 

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 not medically necessary. Our physician reviewer found the enrollee has low back pain. The records do not support that she has tried conservative treatment.

The submitted documentation indicates treatment for knee pain, but do not document greater than 3 months of treatment with conservative methods for the low back pain. The records do not support that the facet joint injections are reasonable or 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 not been met. Therefore, we decided that the Plan does not have to pre-approve facet joint injections.