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 this request is medically necessary. The Plan denied your request. The Plan says the use of Keytruda for the enrollee's condition have not been demonstrated in the peer-reviewed literature.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Keytruda. Our reviewer says that the requested drug is not medically reasonable and necessary. Our physician reviewer found the requested use of Keytruda is not FDA-approved for the enrollee's diagnosis. In addition, the use of Keytruda is not supported by one of the major drug compendia or by clinical research that appears in an approved medical journal. In this case, Keytruda is only in phase II trials and is not recommended by the National Comprehensive Cancer Network for 1st line 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 Keytruda have not been met. Therefore, we decided that the Plan does not have
to pre-approve Keytruda.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Nulojix.
You asked the Plan to pre-approve Nulojix. The Plan denied your request. The Plan says that the drug is not supported for use in combination with Basiliximab induction and Mycophenolate Mofetil.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved 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 Nulojix. Our physician reviewer found that the requested use of Nulojix is not FDA-approved for the enrollee's diagnosis. However, the use is supported by clinical research that appears in a CMS-approved medical journal. A review of literature from the New England Journal of Medicine from Vincenti et al January 2016 shows outcomes with renal transplantation with use of belatacept (Nulojix) reviewed. The use has been shown efficacy in renal transplantation to prevent rejection. The use is not listed as not indicated, not supported or not recommended in any of the compendia. The documentation does 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 Nulojix have been met. Therefore, we decided that the Plan has to pre-approve Nulojix.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.

You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee's problems are secondary to missed dialysis, and there is no documented of skilled need.

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 the admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no skilled nursing needs identified. The documentation does not support that skilled services are required on a daily basis in a skilled nursing facility on an inpatient basis. As a practical matter, the enrollee does not require the necessary services on an inpatient basis, in a skilled nursing facility. 

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 admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve transurethral waterjet ablation of prostate.

You asked the Plan to pre-approve transurethral waterjet ablation of prostate. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.

The Plan follows Medicare rules. Medicare rules say that transurethral waterjet ablation of prostate is only covered for certain indications.

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 transurethral waterjet ablation of prostate. Our reviewer says that the documentation does not support that the requested services are medically reasonable or necessary. Our physician reviewer found the enrollee has benign prostatic hyperplasia and lower urinary tract symptoms managed with tamsulosin. Post void residual is 125 cc. Prostate size is 180 cc. Elevated prostate-specific antigen (PSA) (6.3 ng/mL) was evaluated with needle biopsy November 16, 2020 and was benign. The documentation does not support that the enrollee meets criteria for the requested procedure as the prostate volume is not 30-150 cc in volume. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of transurethral waterjet ablation of prostate have not been met. Therefore, we decided that the Plan does not have to pre-approve transurethral waterjet ablation of prostate.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor.

You asked the Plan to pre-approve a therapeutic continuous glucose monitor. You say that this device is medically necessary to manage your medical condition. The Plan denied your request. The Plan says the coverage criteria for this device have not been met.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. 

We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least three daily injections Based on this information, we decided that Medicare rules for coverage of a therapeutic continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA - a facet joint denervation procedure)

You asked the Plan to pre-approve RFA. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because the Plan already approved two levels so this additional level is not covered by Medicare.

The Plan follows Medicare rules. Medicare rules state that one to two level of facet joint interventions are allowed per session per spine region except under unique circumstances with sufficient documentation of 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 RFA. Our reviewer says that the enrollee does not meet the Medicare criteria for a radiofrequency ablation beyond the 2 levels that were already approved by the Plan. Our physician reviewer found the original request was for RFA at 3 levels (codes 64635 and 64636x2). The Plan approved one each of 64635 and 64636. Per Medicare coverage criteria, one to two levels, either unilateral or bilateral, are allowed per session per spine region. Because two levels have already been approved, the additional level request does not meet the criteria for coverage.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of RFA have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation (RFA - a facet joint denervation procedure)
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex procedure.

You asked the Plan to pre-approve the Vertiflex procedure. You say that this request is medically necessary.
The Plan denied your request. The Plan says the requested procedure is considered experimental and
investigational.

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 Vertiflex procedure. Our reviewer
says that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found the Vertiflex device is experimental. More research is needed to show safety and
efficacy of the device.

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 Vertiflex procedure have not been met. Therefore, we decided that the Plan
does not have to pre-approve the Vertiflex procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair.

You asked the Plan to pre-approve a power wheelchair. You say that this item is medically necessary for your condition. The Plan denied your request. The Plan says this item is not medically needed at this time.

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. The file shows that you do not have a mobility deficit that impairs your participation in MRADLs. In this case, there are no medical records which document your mobility deficit. The Plan did not receive information with medical records documenting the need for this equipment.

This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a computed tomography (CT), heart.

You asked the Plan to pre-approve a computed tomography, heart, without contrast material, with quantitative evaluation of coronary calcium (75571). You say that you need the CT to see if there is calcium in your arteries. The Plan denied your request. The Plan says the request for the quantitative calcium score would be considered a screening service.

The Plan must follow Medicare rules. Medicare rules say that CT scans 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 a computed tomography, heart, without contrast material, with quantitative evaluation of coronary calcium (75571). Our reviewer says that the CT is not medically necessary. Our physician reviewer found it was not clear from the documentation why the physician ordered this test and how it would change the treatment options for this patient who has high cholesterol and intolerant of statins. Regardless of the CT score, this patient would be a candidate for more aggressive cholesterol lowering medication and lifestyle changes. Therefore, this request for CT will be considered 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 a computed tomography, heart, without contrast material, with quantitative
evaluation of coronary calcium (75571) have not been met. Therefore, we decided that the Plan does not have to pre-approve a computed tomography (CT), heart.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an oral appliance for treatment of sleep apnea.
You asked the Plan to pre-approve the oral appliance. You say that it is felt that this is necessary. The Plan denied your request. The Plan says criteria for coverage are not met.
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 oral appliance. Our reviewer says that the requested item is not considered medically reasonable and necessary in this case. Our physician reviewer found the patient is a 71-year-old female with an abnormal sleep study. Oral appliance is requested due to difficulty keeping continuous positive airway pressure (CPAP) device mask on during sleep. The physical findings and other documentation did not reveal why it was difficult to keep the CPAP mask device on during sleep to help justify the use of a different device. Therefore, based on the provided records not being sufficient to support this request, the oral adaptive device does not meet criteria and will be considered not 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 the oral appliance have not been met. Therefore, we decided that the Plan does not have to pre-approve an oral appliance for treatment of sleep apnea
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a back brace (L0650) and collar (L0174) provided January 29, 2021.
You asked the Plan to pay for a back brace and collar. You say that you would like these claims reprocessed for medical necessity. The Plan denied your request. The Plan says Medicare does not provide payment when the enrollee is contacted through an unsolicited phone call.
The Plan follows Medicare rules. Medicare rules say that a supplier may not contact an individual by telephone regarding the furnishing of a covered item except under specific circumstances.
We looked at the file and Medicare rules. The Plan states that this item may have been ordered by an
unsolicited outreach telephone call to the enrollee, and this request was not initiated by the enrollee or the
enrollee's treating physician. The record does not show that written permission was obtained to make contact
by telephone regarding the furnishing of this item. The record does not show that contact was initiated
regarding an item already furnished to the enrollee or another item furnished to the same enrollee within the
past 15 months. Based on this information, we decided that Medicare rules for coverage of a back brace and
collar have not been met. Therefore, we decided that the Plan does not have to pay for a back brace (L0650)
and collar (L0174) provided January 29, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex procedure.
You asked the Plan to pre-approve the Vertiflex procedure. You say that this request is medically necessary. The Plan denied your request. The Plan says the requested procedure is considered experimental and investigational.
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 Vertiflex procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found current evidence based medical guideline and peer reviewed literature do not fully support the spinal decompression device procedure over the 'gold standard' of lumbar laminectomy. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of this device for this enrollee's medical condition as discussed above. Federal Drug Administration indications include implantation of the Vertiflex device at one or two adjacent lumbar levels in patients with moderate spinal stenosis in whom operative treatment is indicated at no more than two levels, from L1 to L5. This enrollee has multiple degrees
of spinal stenosis, many not at FDA indicated levels of "moderate" spinal stenosis (including the planned level
of implantation at L4-5.) The requested procedure will not be considered 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 the Vertiflex procedure have not been met. Therefore, we decided that the Plan
does not have to pre-approve the Vertiflex procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for dermatology services provided on February 3, 2021, to April 8, 2021, by an out of network (OON) provider.
You asked the Plan to pay for dermatology services. You say that you have an on-going skin problem that requires treatment. The Plan denied your request. The Plan says prior authorization was not obtained for services rendered by an OON 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 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 need for this care was known
prior to leaving the service area and was not an emergency. 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 dermatology services provided on February 3, 2021, to April 8,
2021, by an out of network (OON) provider
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 admission. You say that this care is medically necessary. The Plan denied your request. The Plan states Medicare coverage criteria are not met.

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 skilled nursing facility admission. Our reviewer says that the medical records do not show that daily skilled services are not necessary. Our physician reviewer found no specific skilled nursing services are identified. The documentation does not support that you require skilled therapy services daily in an inpatient skilled nursing facility. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of skilled nursing facility admission 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for wound care equipment (A6253, A4450, A6197) provided on January 20, 2021, by an out of network (OON) provider.
You asked the Plan to pay for wound care equipment. You say that you would like this claim reprocessed for medically necessity. The Plan denied your request. The Plan says prior authorization was not obtained for these services rendered by an OON 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 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 wound care equipment (A6253, A4450, A6197)
provided on January 20, 2021, by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing (81455) provided February 1, 2021.
You asked the Plan to pay for the genetic testing. You say that the testing was 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 genetic testing procedures submitted with code 81455 are unlikely to impact therapeutic decision-making in the clinical management of the patient and will be denied as not medically necessary. We looked at the file and Medicare rules. The service at issue is not covered by Medicare. Based on this information, we decided that Medicare rules for coverage of the genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing (81455) provided February 1, 2021.