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

We decided that the Plan does not have to pre-approve a chemotherapy regimen with carboplatin, atezolizumab, and etoposide.

You asked the Plan to pre-approve the requested regimen. You say that the enrollee's cancer has small cells consistent with neuroendocrine features. Pathology shows Merkel cell carcinoma. It is felt this regimen would be helpful as second-line treatment. The Plan denied your request. The Plan says the use of the requested combination is not supported by the 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 the requested regimen. Our reviewer says that the requested treatment is not considered reasonable and necessary for this condition. Our physician reviewer found the enrollee has Merkel cell carcinoma and has failed treatment with a programmed death-ligand 1 (PD-L1) inhibitor, Keytruda. The requested regimen is useful for extensive small cell lung cancer, which is not what the enrollee has. In addition, use of another PD-L1 inhibitor, atezolizumab, would not be supported due to a recent failure of another drug of this class.

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 regimen have not been met. Therefore, we decided that the Plan does not have to pre-approve a chemotherapy regimen with carboplatin, atezolizumab, and etoposide.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an injection of Atezolizumab 10mg (J9022) and an
injection of Bevacizumab 10mg (J9035).

You asked the Plan to pre-approve Atezolizumab and Bevacizumab. You say that the drugs are medical
necessary. The Plan denied your request. The Plan says the drugs are not medically necessary and the
compendia does not show that they are used for this patient's diagnosis.

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 Atezolizumab and Bevacizumab. Our
reviewer says that the service is not medically necessary. Our physician reviewer found the requested use of the
drugs are not FDA-approved for the enrollee's diagnosis and there is no clinical research or compendia
supporting its use for the enrollee's diagnosis.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Atezolizumab and Bevacizumab have not been met. Specifically, the requested
drugs are not FDA approved for the enrollee's diagnosis. This means they are not medically necessary.
Therefore, we decided that the Plan does not have to pre-approve an injection of Atezolizumab 10mg (J9022)
and an injection of Bevacizumab 10mg (J9035).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xywav Sol 0.5 mg/ml 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 this medication is denied due to benefit exclusion.

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 Xywav Sol 0.5 mg/ml for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Craftmatic mattress.

You asked the Plan to pre-approve a Craftmatic mattress. You say that this item is necessary for your condition. The Plan denied your request. The Plan says this is not a covered service.

The Plan must follow Medicare rules. Medicare rules say that a replacement mattress will be covered for a beneficiary owned hospital bed. 

We looked at the file and Medicare rules. The file indicates that you do not own a hospital bed that requires a replacement mattress. Based on this information, we decided that Medicare rules for coverage of a Craftmatic mattress have not been met. Therefore, we decided that the Plan does not have to pre-approve a Craftmatic mattress.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a grab bar.

You asked the Plan to pre-approve a grab bar. The Plan denied your request. The Plan says this item is not a covered benefit.

The Plan covers all items that Medicare covers. Medicare rules state that grab bars are not covered because they are not primarily medical in nature. 

While a grab bar may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a grab bar.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of physical therapy visits (CPT code 97164), for the enrollee.

You asked the Plan to pre-approve the physical therapy visits. You say that the services are necessary. The Plan denied your request. The Plan says the enrollee received many visits for this condition and their symptoms, motion and strength have not greatly changed. The Plan states detail is lacking in the skills that require further treatment of the enrollee's condition by a physical therapist.

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 physical therapy 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 the additional requested therapy is not generally accepted as specific and effective therapy for the enrollee's condition beyond what was approved by the health plan. The enrollee has had prior extensive therapy for this condition and the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or for physical therapy, by or under the supervision of a therapist. The enrollee has been instructed in a home exercise program. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration.

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 physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve continuation of physical therapy visits (CPT code 97164), for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve auricular peripheral stimulation.

You asked the Plan to pre-approve the stimulation. You say that this is medically necessary. The Plan denied your request. The Plan says auricular peripheral stimulation is not covered.

The Plan must follow Medicare rules. Medicare rules say that auricular peripheral stimulation is not covered. 

Medicare does not consider the requested services to be medically necessary. Based on this information, we decided that Medicare rules for coverage of the stimulation have not been met. Therefore, we decided that the Plan does not have to pre-approve auricular peripheral stimulation.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for CxBladder testing (0012M) provided by an out of network (OON) provider.

You asked the Plan to pay for CxBladder testing. You say that this is a Medicare-covered service. The Plan denied your request. The Plan says this was not authorized.

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 CxBladder testing (0012M) provided by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc-One.

You asked the Plan to pre-approve Synvisc-One. The Plan denied your request. The Plan says the enrollee has not tried and failed Monovisc and Orthovisc.

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 Synvisc-One. Our physician reviewer found that the enrollee has pain related to osteoarthritis of both knees, diagnosis confirmed with imaging studies. She has failed conservative treatment. The Plan requires a trial of Monovisc and Orthovisc before they will approve the requested drug. The enrollee has not tried and failed the required drugs. There is no indication that the plan's required drugs would likely be less effective, 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 Synvisc-One have not been met. Therefore, we decided that the Plan does not have to pre-approve Synvisc-One.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar sacral orthosis (LSO) (L0650).

You asked the Plan to pay for a LSO. You say that the item is medically necessary. The Plan denied your request. The Plan says there was insufficient documentation submitted.

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 pay for a LSO. Our reviewer says that the requested item is not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not support that the lumbar-sacral orthosis was prescribed for one or more of the covered indications in this case, as there is insufficient documentation of a credible evaluation of the enrollee and a credible physical examination of the back.

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 LSO have not been met. Specifically, the documentation submitted does not indicate a medical necessity for the item requested. Therefore, we decided that the Plan does not have to pay for a lumbar sacral orthosis (LSO) (L0650).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient psychiatric care.

You asked the Plan to pre-approve this service. You say that continued inpatient psychiatric care is medically necessary for the enrollee. The Plan denied your request. The Plan says that the enrollee does not meet criteria for coverage of continued inpatient psychiatric care.

The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment.

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 this service. Our reviewer says that continued inpatient psychiatric care is not medically necessary. Our physician reviewer found that the enrollee was admitted to the acute inpatient psychiatric hospital with a Major Neurocognitive Disorder with Behavioral Disturbance. It was not expected that this enrollee would improve in a reasonable period of time as he was not showing any dangerousness to self or others, auditory or visual hallucinations, and was without any recent aggressive behaviors, while not showing any acute threats of safety. It did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the date in question as he did not have any suicidal or homicidal thoughts, auditory or visual hallucinations or recent abnormal behaviors. It did not appear that the services for the date in question were reasonably expected or medically necessary to improve the patient's condition or were for the purpose of a diagnosis.

Based upon the review of the records provided, this patient does not meet the criteria for acute inpatient mental health treatment beyond the date in question.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pre-approve continued inpatient psychiatric care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve fluoride carriers (21089).

You asked the Plan to pre-approve fluoride carriers. You say that the item is not a dental service, but a medical
service due to the patient's diagnosis and treatment. The Plan denied your request. The Plan says Medicare does
not cover primary dental services provided for the care and treatment of teeth or structures directly supporting
teeth, regardless of cause or complexity.

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
fluoride carriers (21089).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network cardiologist for the enrollee.

You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says this must be provided 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 a referral to an out-of-network cardiologist for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Eyelea.

You asked the Plan to pre-approve Eyelea. The Plan denied your request. The Plan says the enrollee has not met the step therapy requirements.

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 Eyelea. Our reviewer says that Eyelea is not medically reasonable and necessary for the enrollee in this case. Our physician reviewer found that there is medical evidence that Eyelea is equivalent to bevacizumab (Avastin) in this particular case. Based on the medical records, the enrollee has macular edema with visual acuity of 20/25 in the right eye and 20/30 in the left. Eylea would only be considered superior to the plan's recommended alternative (bevacizumab) in the case of diabetic macular edema with visual acuity worse than 20/50. There is evidence in the medical literature that Eylea is equivalent to Avastin (bevacizumab) when visual acuity is 20/50 or better, but superior with poorer central acuity. Therefore, it is not medically necessary for the patient to be treated with aflibercept over bevacizumab.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Eyelea have not been met. Therefore, we decided that the Plan does not have to pre-approve Eyelea.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve office visits (99214) to be provided by an OON psychiatrist.

You asked the Plan to pre-approve OON psychiatry visits. You say that you would like to continue seeing an
OON psychiatrist. The Plan denied your request. The Plan says these services are available in-network. The
Plan has also indicated that they have approved these services with an in-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
office visits (99214) to be provided by an OON psychiatrist.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of lumbar spine (72148).

You asked the Plan to pre-approve the MRI. You say that why would this be not necessary when you have chronic back pain that is shifting to your leg. You have a right to have a medical item or service to be covered by the plan. The Plan denied your request. The Plan says the records do not support that this requested service is medically necessary.

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 items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has tried NSAIDs, muscle relaxants, Lyrica, and lidoderm with limited benefit. She also had facet joint block in 2019 and was not deemed a surgical candidate. She refused stimulator treatment. MRI in 2019 showed foraminal stenosis at several levels most pronounced L4-5 where there is moderate stenosis right neural foramen. There was no report of the enrollee having significant worsening, failure of PT, or being a surgical candidate, and there was no evidence of a red flag diagnosis which would warrant repeat MRI at this time. Therefore, this request for lumbar MRI will be considered not medically necessary as there was no clear explanation as to how it would lead to the patient having an improved outcome.

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 magnetic resonance imaging (MRI) of lumbar spine (72148).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the mandibular partial denture and the maxillary
complete denture.

You asked the Plan to pre-approve the mandibular partial denture and the maxillary complete denture.. You say
that you need a replacement for your existing dentures. The Plan denied your request. The Plan says coverage
for dentures is limited to once per 60 months.

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 in
excess of those covered under this benefit. The Plan has provided evidence that you received mandibular and
maxillary dentures within the last 60 months. Therefore, we decided that the Plan does not have to pre-approve
the mandibular partial denture and the maxillary complete denture.

Your complaint about having never received your dentures is not a valid appeal for medical coverage. This part
of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a
decision about these types of complaints.