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

We decided that the Plan does not have to pre-approve Prolia.
You asked the Plan to pre-approve Prolia. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug is not medically necessary.
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 Prolia. Our reviewer says that the documentation does not support that the requested drug is medically reasonable or necessary. Our physician reviewer found the enrollee has prostate cancer. Prolia (denosumab) is indicated for osteoporosis prophylaxis in men with non-metastatic prostate cancer, who are taking androgen deprivation therapy. The enrollee's prostate cancer is metastatic. Therefore, the enrollee does not meet criteria for the requested drug. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve second opinion services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve these OON services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services can be provided to the enrollee by a network provider.
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 second opinion services to be provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the 2 crowns - porcelain/ceramic (D2740) provided January 20, 2020.
You asked the Plan to pay for the dental services. You say that the cost of the 2 crowns should be covered according the dental plan that you were signed up for (70% co-insurance for crowns). The Plan denied your request. The Plan says this request exceeds the benefit limitation.
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 health plan contract says that the plan only covers for 1 crown a year. The plan has approved for 1 crown for this same date of service. 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 2 crowns - porcelain/ceramic (D2740) provided January 20, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve wheelchair accessories.
You asked the Plan to pre-approve wheelchair accessories. The Plan denied your request. The Plan says your upper limb strength and function are adequate to control power options using their own switches.
The documentation shows a transit kit was requested. The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. The item at issue is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home.
The documentation shows a privacy flap and gel arm pads were requested. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The privacy flap is a convenience item. The records do not show why gel arm pads are needed above the standard arm pads The items at issue do not serve a purpose that is primarily medical in nature.
The documentation shows that an expandable control system. 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 requested system. Our physician found that the documentation indicates you have sufficient strength and function to control the power features through their own individual switches. Therefore, the requested expandable control system is not medically necessary.
We looked at the physician's review, the file, and the Medicare rules. Based on this information, we decided that the Medicare rules for coverage of the requested items have not been met. Therefore, we decided that the Plan does not have to pre-approve wheelchair accessories.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for assistant surgeon services for the percutaneous vertebroplasty and the arthrodesis services provided on April 16, 2019.
You asked the Plan to pay for assistant surgeon services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services provided are not medically necessary.
The Plan follows Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. Medicare rules say that for procedures with an assistant surgery indicator of 0, the payment restriction for assistants at surgery applies to this procedure unless supporting documentation is submitted to establish medical necessity. In this case, you billed assistant surgery services for CPT codes 22510 and 22600. The Medicare Fee Schedule Database contains a surgical indicator of 0 for these procedures. 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 assistant surgeon services. Our reviewer says that the documentation does not support that the assistant surgeon services were medically reasonable or necessary. Our physician reviewer found the enrollee received spine surgery. The documentation does not support that there was a need for an assistant surgeon for these services. Therefore, these services are not covered.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of assistant surgeon services have not been met. Therefore, we decided that the Plan does not have to pay for assistant surgeon services for the percutaneous vertebroplasty and the arthrodesis services provided on April 16, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve at-home UV light therapy.
You asked the Plan to pre-approve the requested services. You say that a home light is recommended due to its ease of use, effectiveness, and relative safety. The Plan denied your request. The Plan says the requested treatments are available in the physician's office. Medicare does not cover services for the purpose of convenience.
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 the requested services. Our physician reviewer found that it has not been sufficiently demonstrated that an ultraviolet multidirectional light therapy system in 6-foot cabinet, including bulbs/lamps, timer and eye protection, is medically necessary for the enrollee in this case. It is not stated that the enrollee would be unable to get UV light therapy due to COVID-19, in the physician's office. It is not medically reasonable and necessary for the enrollee to receive in-home treatments. The services in-office can provide safe and effective treatment for the enrollee in this case. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve at-home ultraviolet (UV) light therapy.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve outpatient physical therapy visits.
You asked the Plan to pre-approve the visits. You say that this is medically necessary. The Plan denied your request. The Plan says the records do not show that the level of functioning continues to improve with therapy.
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 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 there is no indication that residual deficits could not be addressed via a home exercise program. Therefore, this request is deemed not medically necessary as it is deemed maintenance therapy. 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 visits have not been met. Therefore, we decided that the Plan does not have to pre-approve outpatient physical therapy visits.
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 you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested admission is not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee was medically stable. The enrollee required minimal assistance to contact guard assistance for upper body dressing and moderate assistance with lower body dressing. The enrollee required maximum assistance with toileting. The documentation does not support that the enrollee required an inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's rehabilitation needs can be met at a lower level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve MRI of the upper extremity without contrast for the enrollee.
You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your request. The Plan says this is a duplicate of a study that had already been approved.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 the MRI. Our reviewer says that the requested MRI is not medically reasonable or necessary. Our physician reviewer found in this case, there was already an approval code for the same study that is on file in the enrollee's records. The approval is still in effect. There is no documentation of the results of prior imaging or if there are plans to use this approval. The approved study may be sufficient for the evaluation of the current clinical condition. The review has determined that the requested MRI of the upper extremity without contrast 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 the MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve MRI of the upper extremity without contrast for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 31 indwelling Foley catheters per month.
You asked the Plan to pre-approve the 31 indwelling Foley catheters per month. You say that the enrollee needs the requested item in order to survive. You say that this is a threatening issue because the enrollee cannot urinate without the requested item. You say that this item, and the amount needed every month, is medically necessary. The Plan denied your request. The Plan says the records provided do not support he medical necessity for the requested item.
The Plan follows Medicare rules. Medicare rules say that non-routine catheter changes are covered when documentation substantiates medical necessity. 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 31 indwelling Foley catheters per month. Our reviewer says that the medical records provided do not support the medical necessity of 31 indwelling Foley catheters per month. Our physician reviewer found the enrollee has urinary incontinence, incomplete bladder emptying, and an overactive bladder. She currently manages her bladder with intermittent self-catheterization and is approved for 450 intermittent catheters per month. 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 31 indwelling Foley catheters per month have not been met. Therefore, we decided that the Plan does not have to pre-approve 31 indwelling Foley catheters per month.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the records provided support the need for LTACH care. The Plan denied your request. The Plan says the enrollee does not meet the criteria for coverage of LTACH care. The Plan says that the enrollee is improving in the acute hospital setting and is advancing to a level whereby she can complete her full course of care in the hospital and then transition to a high acuity skill nursing facility.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is currently undergoing treatment at an acute care hospital (ACH), having presented with dyspnea that was complicated by a difficult intubation and cardiopulmonary arrest. The enrollee was briefly intubated/ventilated, but is no longer intubated/ventilated. There is no evidence that the enrollee requires services that are not currently available. There is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such a time that no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care needs. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on January 15, 2019 by a non-
Medicare certified provider.
You asked the Plan to pay for the office visit. You say that you would like the plan the plan to reconsider their
denial. The Plan denied your request. The Plan says the services received are not a covered benefit.
Medicare rules say that Medicare pays for services only when they are furnished by a provider or supplier
enrolled in the Medicare program.
Review of the file shows that the provider was not Medicare-certified during the date of service 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 office
visit provided on January 15, 2019 by a non-Medicare certified provider.
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 you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug 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 documentation does not support that the requested drug is medically reasonable or necessary. Our physician reviewer found the requested use of Keytruda is not FDA-approved for the enrollee's diagnosis. The requested use is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. Therefore, the enrollee does not meet criteria for the requested drug. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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 the assembly and operation of a pump with an oxygenator or heat exchanger (99190) provided on January 7, 2020. 
 
You asked the Plan to pay for the assembly and operation of a pump with an oxygenator or heat exchanger. You say that this was a necessary service. The Plan denied your request. The Plan says payment for this service is included in the DRG. 
 
The Plan must follow Medicare rules. The rules say that there is no payment under the OPPS for services that CMS designates to be "inpatient-only" services. These services have an OPPS status indicator of "C" in the OPPS Addendum B and are listed together in Addendum E of each year's OPPS/ASC final rule.  
 
The service at issue in this appeal was billed with CPT code 99190. This code is listed with a status indicator of "C" on Addendum B of the 2020 OPPS/ASC final rule. This means the service has been designated as "inpatient only", and therefore must be billed as part of an inpatient admission. Therefore, we decided that the Plan does not have to pay for the assembly and operation of a pump with an oxygenator or heat exchanger (99190) provided on January 7, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Farxiga for the enrollee. 
 
You asked the Plan to pre-approve this drug. You say that the enrollee has congestive heart failure and diabetes mellitus type 2. The Plan denied your request. The Plan says that this medication is not covered under Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered 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 Farxiga for the enrollee.  
 
Benefits for this drug 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on December 24, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are available in-network.
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 has network providers available who can provide the services at issue in this appeal. 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 the medical services provided to the enrollee by an out-of-network provider on December 24, 2019.
Appeal type: Outpatient Mental Health
Decision: Favorable

We decided that the Plan has to pre-approve float therapy.
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 services are experimental and not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan states that the services are not medically necessary based on your medical documentation; however, no medical records were received. MAXIMUS requested these records from the Plan but a response was not received. There is no documentation to support that the services are not medically necessary. Therefore, we decided that the Plan has to pre-approve float therapy.