Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health services for the enrollee.You asked the Plan to pre-approve the services. You say that you could hurt yourself if you're home alone.The Plan denied your request. The Plan says the records do not show a plan of care developed with a physician.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 services. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found the request for home health skilled nursing services do not meet the criteria for this request per Medicare Benefit Policy Manual, Chapter 7. The records do not show that skilled nursing services are required to effectively provide treatment, care, and/or services in order to improve the patient's condition, or to establish/perform a maintenance program to maintain the patient's condition and/or prevent deterioration. The physician progress note indicates the patient takes Lasix once daily. There is no evidence that this patient is home bound, has complex wound care, IV antibiotics, or other skilled nursing need.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 services have not been met.Therefore, we decided that the Plan does not have to pre-approve home health services for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sacroplasty for the enrollee.You asked the Plan to pre-approve the surgery. You say that this is medically necessary.The Plan denied your request. The Plan says this is not a covered service.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 surgery. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the requested surgery remains experimental for the treatment of osteoporosis fractures in the sacrum. More research is needed to show safety and efficacy.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 surgery have not been met.Therefore, we decided that the Plan does not have to pre-approve sacroplasty for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power operated vehicle (K0812).You asked the Plan to pre-approve a power operated vehicle. You say that you would like this device to help you be more independent.The Plan denied your request. The Plan says this is not medically necessary.The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 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 a power operated vehicle. Our reviewer says that the requested device is not shown to be medically necessary at this time. Our physician reviewer found he records indicate the patient has a personal mobility deficit but the documentation is not clear that it impairs participation in MRADLs. The records do not indicate an objective evaluation of the upper extremities that indicates that he is unable to use a walker, cane or manual wheelchair, or an in home assessment with measurements that indicate he can safely operate a PMD in the home. There is no trial of a PMD documented.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a power operated vehicle have not been met.Therefore, we decided that the Plan does not have to pre-approve a power operated vehicle (K0812).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Zarxio for the enrollee.You asked the Plan to pre-approve the drug. You say that this is medically necessary.The Plan denied your request. The Plan says the clinical criteria for coverage and the step therapy requirements were 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 the drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found the review relates to a request for Zarxio to treat agranulocytosis related to cancer therapy. The diagnosis of febrile neutropenia is listed in the submitted office notes. No mention of fever is made in the history section and no fever is documented in the vital signs. The enrollee's absolute neutrophil count is 1,100 on 5/18/20. The documentation does not indicate that any other growth factor, such as Neupogen or Nivestym have been tired to treat the enrollee. He has not previously been treated with Zarxio. Per the NCCN Guidelines Version 2.2020 Hematopoietic Growth Factors updates page, An FDA-approved biosimilar is an appropriate substitute for Fligrastim and Pegfilgrastim. Neupogen is Filgrastim and Nivestym and Zarxio are both FDA approved biosimilars. The plan's required drugs would not likely be less effective and/or likely have adverse effects for the enrollee.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the drug have not been met.Therefore, we decided that the Plan does not have to pre-approve Zarxio for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea Group 3 power wheelchair (PWC) with accessories.You asked the Plan to pre-approvethese 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 a Group 3 PWC 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 a personal mobility deficit that impairs mobility-related activities of daily living (MRADLs) in the home. The mobility limitation can be sufficiently and safely resolved by the use of an appropriately fitted lightweight manual wheelchair, per a durable medical equipment (DME) consulting evaluation. The documentation states he does not have the consistency in function to operate a power wheelchair. The Group 3 PWC is therefore 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 these services have not been met.Therefore, we decided that the Plan does not have to pre-approvea Group 3 power wheelchair (PWC) with accessories.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Jardiance for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says Medicare says Part B programs can only provide limited benefits for prescription drugs.
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 Jardiance for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvean automatic blood pressure monitor (BPM).You asked the Planto pre-approvethe BPM. You say that this device is needed in order to allow for BP checks during virtual office visits.The Plandenied your request. The PlansaysMedicare does not cover BPMs aside for use with home dialysis.The Plan must follow Medicare rules. The rules say that Medicare covers home blood pressure monitors only for enrollees who are on home dialysis, or those who meet the criteria for white coat hypertension and require ABPM to confirm a diagnosis of hypertension. The records do not show that this monitor is requested in the setting of home dialysis services, or that this request is for evaluation of suspected white coat hypertension. Although monitoring blood pressure in the home may be appropriate in this case, neither Medicare nor the Plan provides coverage of this item in this situation.Therefore, we decided that the Plandoes not haveto pre-approvean automatic blood pressure monitor (BPM).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forresin-based composite -four ormore surfaces or involving incisal angle (anterior) (D2335), resin-based composite -one surface, posterior (D2391) and resin-based composite -two surfaces, posterior (D2392) provided on December 23, 2019.You asked the Plan to pay forthe dental services. You say that you did not find any details about non-coveredservices.The Plan denied your request. The Plan says the services are not a covered benefit under the 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, the requested items or services are not among those covered under this benefit. The services are not listed in your EOC as a covered benefit; therefore, the services are not covered.Therefore, we decided that the Plan does not have to pay forresin-based composite -four or more surfaces or involving incisal angle(anterior) (D2335), resin-based composite -one surface, posterior (D2391) and resin-based composite -two surfaces, posterior (D2392) provided on December 23, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to the physician at an out-of-network provider.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says the service is available within the network at a non-tertiary level of care.
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 a referral to the physician at an out-of-network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for facet joint injections (64636) provided on December 17, 2019.
You asked the Plan to pay for the facet joint injections. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support the services billed.
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, the CPT Code Manual definition of code 64636 is destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional facet joint (List separately in addition to code for primary procedure). We asked our coder 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 facet joint injections. Our reviewer says that CPT code 64636 does not meet criteria for billing or reimbursement consideration. Our reviewer found the medical records provided indicate that on 1 facet joint received RFA, therefore, CPT 64636 cannot be verified. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the facet joint injections have not been met. Therefore, we decided that the Plan does not have to pay for facet joint injections (64636) provided on December 17, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Androgel 1.62% gel.You asked the Plan to pre-approve the gel. You say that this is medically necessary.The Plan denied your request. The Plan says the enrollee does not have a pharmacy 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 Androgel 1.62% gel.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network provider for magnetic resonance imaging (MRI).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 available from network providers.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 a referral to an out-of-network provider for magnetic resonance imaging (MRI).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Glyburide (J8499).You asked the Plan to pre-approveGlyburide. You say that the enrollee has been stable on this medication.The Plan denied your request. The Plan says coverage of this medication is the responsibility of the enrollee's prescription drug 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-approveGlyburide (J8499).Benefits for Glyburidemay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approvea drug regimen of Keytruda (J9271), pemetrexed (J9305), carboplatin (J9045), dexamethasone sodium phosphate(J1100), fosaprepitant (J1453), palonosetron HCL (J2469), and diphenhydramine (J1200).You asked the Plan to pre-approvea drug regimen of Keytruda and supporting drugs. You say that the enrollee's case warrants this combination treatment.The Plan denied your request. The Plan says that this drug regimen is not indicated for the enrollee's cancer.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 a drug regimen of Keytruda and supporting drugs. Our reviewer says that the requested drugs are supported for use in this case. Our physician reviewer found the combination of carboplatin/pemetrexed/pembrolizumab is approved by the FDA and is considered the standard of care. The enrollee is 4 years from prior carboplatin/pemetrexed and retreatment is reasonable especially with addition of pembrolizumab. The documentation 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 a drug regimen of Keytruda and supporting drugs have been met.Therefore, we decided that the Plan has to pre-approvea drug regimen of Keytruda (J9271), pemetrexed (J9305), carboplatin (J9045), dexamethasonesodium phosphate(J1100), fosaprepitant (J1453), palonosetron HCL (J2469), and diphenhydramine (J1200).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay foroutpatient hospital services (G0463) provided on November 4, 2019.You asked the Plan to pay forthe outpatient hospital services. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says the members claim would be covered under Original Medicare as it is responsible for coverage of Part Bbenefits starting on the date of election until the last day of the month in which hospice is revoked.Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal.Therefore, we decided that the Plan does not have to pay foroutpatient hospital services (G0463) provided on November 4, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided on May 22, 2019.
You asked the Plan to pay for the physical therapy services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says your other insurance coverage was your primary carrier on this date of service.
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer. The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has requested the primary carrier's EOB for the services at issue. As the secondary insurer, the Plan cannot be held responsible for the physical therapy services until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for physical therapy services provided on May 22, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compounded medications (J1170 and J3490) for an implanted pain pump.You asked the Plan to pre-approve the compounded medications. You say that you would like reconsideration as these drugs are medically necessary.The Plan denied your request. The Plan says pharmacies cannot directly bill for compounded medications to fill a pain pump as this is an incident to service and should be reflected in the physician's bill.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 compounded medications (J1170 and J3490) for an implanted pain pump.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on November 18, 2019 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 has network providers available who can provide 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 November 18, 2019 by a non-participating provider.