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 enrollee is ineligible for Alimta. The Plan denied your request. The Plan says Keytruda may not be used in combination with Taxol and Carboplatin when used for the enrollee's indication.

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. The file shows that Keytruda was requested to be used in combination with Taxol and Carboplatin. 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 physician reviewer found that Keytruda is not FDA-approved in the requested combination. Keytruda is indicated for first-line treatment of metastatic nonsquamous non-small cell lung cancer with no EGFR or ALK genomic tumor aberrations in combination with pemetrexed and platinum chemotherapy. The documentation does not support that the requested drug is safe and effective and otherwise reasonable and necessary 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 Keytruda have not been met. Therefore, we decided that the Plan does not have to pre-approve Keytruda.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home infusion therapy services and supplies with an ineligible provider.

You asked the Plan to pre-approve home infusion therapy services and supplies. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the requested provider is not enrolled in the Medicare program.

The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program. 

Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pre-approve home infusion therapy services and supplies with an ineligible provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.

You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the member does not require the daily skilled therapy or nursing services required to qualify for a skilled nursing facility stay.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a TENS unit.

You asked the Plan to pre-approve the unit. You say that this is medically necessary. The Plan denied your request. The Plan says there is no enrollment in an approved clinical study.

The Plan must follow Medicare rules. Medicare rules say that a TENS unit is covered for chronic low back pain when there is enrollment in a clinical study. 

There is no evidence of enrollment in a clinical study. Based on this information, we decided that Medicare rules for coverage of the unit have not been met. Therefore, we decided that the Plan does not have to pre-approve a TENS unit.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lower partial denture.

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 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, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a lower partial denture.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the IV tubing extension set (code S1015) and infection control supplies (code S8301).

You asked the Plan to pay for the IV tubing extension set and infection control supplies. You say that your anesthesia services were requested by the enrollee's in-network providers. The Plan denied your request. The Plan says the denial of payment for these services is correct, because the billed codes are not valid for Medicare purposes and are not covered.

The Plan must follow Medicare rules. Medicare rules say that procedure codes S1015 and S8301 are not valid for Medicare purposes and are not payable.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the IV tubing extension set and infection control supplies have not been met. Therefore, we decided that the Plan does not have to pay for the IV tubing extension set (code S1015) and infection control supplies (code S8301).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing.

You asked the Plan to pay for the genetic testing. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.

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 genetic testing.
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 IRF admission is medically necessary. The Plan denied your request. The Plan says the enrollee's needs can be met at a different 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 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 based on the medical records provided 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 may require skilled physical therapy and occupational therapy but based on the medical records provided the enrollee does not require treatment in an intensive rehabilitation therapy program. 

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: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for a duplex scan (93925) provided July 7, 2020.

You asked the Plan to pay for the duplex scan. You say that the services were medically necessary. The Plan denied your request. The Plan says the claim did not include a valid place of service.

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 93925 is not supported in the medical record. Specifically, the claim shows an outpatient place of service, however, the records show the enrollee was an inpatient at the time the service was provided. Based on this information, we decided that Medicare rules for coverage of the duplex scan have not been met. Therefore, we decided that the Plan does not have to pay for a duplex scan (93925) provided July 7, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics (L3260).

You asked the Plan to pre-approve foot orthotics. You say that you need the requested item to be able to walk. The Plan denied your request. The Plan says this item is not a covered benefit.

Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. 

Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics (L3260).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve mandibular partial dentures (resin base).

You asked the Plan to pre-approve the dentures. You say that this is medically necessary. The Plan denied your request. The Plan says the benefit has been exhausted.

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 dentures once every five years. 

Dentures were last received less than five years ago on September 3, 2019. Based on this information, we decided that the Plan's rules for coverage of the dentures have not been met. Therefore, we decided that the Plan does not have to pre-approve mandibular partial dentures (resin base).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transportation service (A0427, A0425) provided on March 30, 2020.

You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly for this service.

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 $200 copayment for each one-way, in-network Medicare-covered ambulance trip. 

You have been asked to pay a $200 copayment for the one-way Medicare-covered ambulance trip provided. 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 ambulance transportation service (A0427, A0425) provided on March 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on October 13, 2020.

You asked the Plan to pay for the comprehensive oral evaluation. You say that you had to see a new dentist, and would like this service to be covered. The Plan denied your request. The Plan says this service exceeds the frequency limitation in your benefit plan.

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, comprehensive oral evaluation (D0150) is limited to one procedure every three plan years. The record shows that you received a comprehensive oral evaluation (D0150) on February 7, 2019, and your comprehensive oral evaluation (D0150) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on October 13, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve PET with metabolic evaluation (78608).

You asked the Plan to pre-approve PET with metabolic evaluation. You say that you would like reconsideration because you suffered a head injury and your provider believes this is medically necessary. The Plan denied your request. The Plan says records do not show that member has been diagnosed with dementia.

The Plan follows Medicare rules. Medicare rules say that an FDG PET scan is considered reasonable and necessary in patients with a recent diagnosis of dementia and documented cognitive decline of at least 6 months, who meet diagnostic criteria for both Alzheimer's disease (AD) and Frontotemporal Dementia (FTD) 

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 PET with metabolic evaluation. Our reviewer says that you are not noted to meet diagnostic criteria for either AD and FTD at this time. Our physician reviewer found the requirements of the NCD for coverage would not be met and this service would not be 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 PET with metabolic evaluation have not been met. Therefore, we decided that the Plan does not have to pre-approve PET with metabolic evaluation (78608).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ozempic 2/1.5ml injection for the enrollee.

You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says the medication falls under Part D coverage.

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 Ozempic 2/1.5ml injection for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve arthrodesis.

You asked the Plan to pre-approve arthrodesis, sacroiliac joint, percutaneous or minimally invasive (indirect visualization), with image guidance, includes obtaining bone graft when performed, and placement of transfixing device (27279). You say that the enrollee needs this procedure for pain relief. The Plan denied your request. The Plan says the spine surgery is not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are 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 arthrodesis, sacroiliac joint, percutaneous or minimally invasive (indirect visualization), with image guidance, includes obtaining bone graft when performed, and placement of transfixing device (27279). Our reviewer says that the requested surgery, fusion of the sacroiliac joint, is not medically reasonable or necessary. Our physician reviewer found detailed documentation is not evident of the results from the diagnostic blocks of the bilateral SI joints. Detailed documentation is not evident of 3 positive exam findings to suggest the diagnosis of sacroiliac joint pathology. Detailed documentation is not evident that other plausible causes of pain generators (spine, hip(s) have been comprehensively evaluated and ruled out. Therefore, the requested surgery, fusion of the sacroiliac joint, is not medically reasonable or 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 arthrodesis, sacroiliac joint, percutaneous or minimally invasive (indirect visualization), with image guidance, includes obtaining bone graft when performed, and placement of transfixing device (27279) have not been met. Therefore, we decided that the Plan does not have to pre-approve arthrodesis.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Clobetasol 0.05% shampoo.

You asked the Plan to pre-approve Clobetasol 0.05% shampoo. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested item is not a covered benefit.

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 Clobetasol 0.05% shampoo.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an implant supported crown with dental code D6065.

You asked the Plan to pre-approve dental code D6065. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says dental code D6065 is not covered under the Plan's supplemental dental benefit.

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 code D6065 is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an implant supported crown with dental code D6065.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Synvisc One.

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 that the step therapy requirement is not met.

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 these services. Our reviewer says that the services are medically necessary. Our physician reviewer found the enrollee has a history of rheumatoid arthritis and osteoarthritis of the left knee. She received previous viscosupplementation with Synvisc. Her provider has requested additional viscosupplementation with Synvisc One. Step therapy may only be applied to new prescriptions or administrations of Part B drugs for enrollees that are not actively receiving the affected medication. The requested Synvisc One is medically necessary and 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 these services have been met. Therefore, we decided that the Plan has to pre-approve Synvisc One.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pre-approve immunoassay for tumor antigen (86316).

You asked the Plan to pre-approve immunoassay for tumor antigen. You say that the clinical information provided supports that the requested test is medically necessary. The Plan denied your request. The Plan says that the requested test is not covered because it is being requested in the absence of disease.

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 immunoassay for tumor antigen. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has a diagnosis of diffuse large B-cell lymphoma. The enrollee underwent resection of a well-differentiated neuroendocrine carcinoma of the ileum resected in 2020. Chromogranin A testing is used to monitor neuroendocrine tumors and assess the response to treatment. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of immunoassay for tumor antigen have been met. Therefore, we decided that the Plan has to pre-approve immunoassay for tumor antigen (86316).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for supplemental benefits for the chronically ill.

You asked the Plan to pay for the supplemental benefits. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says you do not meet any of the criteria for coverage of this benefit.

Medicare does not cover this benefit. However, the Plan offers a supplemental benefit for the chronically ill that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the supplemental benefit have not been met. Therefore, we decided that the Plan does not have to pay for supplemental benefits for the chronically ill.