Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the ostomy supplies provided on
December 28, 2020, to August 27, 2021.
You asked the Plan to waive the coinsurance for the ostomy supplies. You say that the cost share is wrong. The
Plan denied your request. The Plan says the cost share was applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 10%
coinsurance for durable medical equipment (DME) and related supplies in 2020 and 20% in 2021.
You have been asked to pay a 10% coinsurance for DME in 2020 and a 20% coinsurance for DME in 2021. the
ostomy supplies fall within the durable medical equipment (DME) and related supplies benefit category. This
means that you have been asked to pay the correct amount based on your contract with the Plan.
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we
decided that the Plan does not have to waive the coinsurance for the ostomy supplies provided on December
28, 2020, to August 27, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of Botox.
You asked the Plan to pre-approve Botox. You say that you are appealing with supporting records. The Plan
denied your request. The Plan says the denial of authorization for this drug is correct, because the Plan requires
a trial of Dysport or Xeomin before it will cover Botox.
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 Botox. Our reviewer says that the
enrollee does not meet the Medicare criteria for a step therapy exception for Botox. Our physician reviewer
found the enrollee has not tried and failed the Plan's preferred drugs of Dysport or Xeomin. the record does not
show that these drugs would likely be less effective and/or 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 Botox have not been met. Therefore, we decided that the Plan does not have to
pre-approve use of Botox.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Entyvio (J3380).

You asked the Plan to pre-approve Entyvio. You say that this is medically necessary. The Plan denied your request. The Plan says step therapy requirements have not been 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 Entyvio. Our reviewer says that the requirements for coverage of Entyvio have not been met. Our physician reviewer found the Plan requires a trial of Stelara before they will approve the requested drug. The case file does not contain documentation of trial and failure of Stelara. The documentation is not sufficient to support that Stelara would likely be less effective or have adverse effects 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 Entyvio have not been met. Therefore, we decided that the Plan does not have to pre-approve Entyvio (J3380).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Livalo.
You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your
request. The Plan says that this is not covered under Part B.
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 Livalo.
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: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment with Fulphila (Q5108, 96372).
You asked the Plan to pre-approve Fulphila. You say that the requested treatment is a medical necessity for the
enrollee. The Plan denied your request. The Plan says step therapy rules for the requested treatment have not
been 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 Fulphila. Our reviewer says that the
requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that the
Plan requires a trial of drugs Neulasta (Pegfilgrastim), Neulasta Onpro (Pegfilgrastim), or Udenyca
(Pegfilgrastim-cbqv) before they will approve the requested drug. The case record does not contain
documentation of trial and failure of the Plan's required drugs. The documentation does not support that the
Plan's required drugs would likely be less effective, and/or would likely have adverse effects 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 Fulphila have not been met. Therefore, we decided that the Plan does not have
to pre-approve treatment with Fulphila (Q5108, 96372).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient services provided from September 7, 2020, to
September 18, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed DRG is not
supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the
reported principal and secondary diagnosis codes.
In this case, you billed the inpatient services provided with diagnosis code A41.51. 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 the services. Our reviewer says that the use of diagnosis code A41.51
is not supported by the records provided. Our physician reviewer found that the documentation was unclear
regarding a diagnosis of sepsis. Even though sepsis is documented in the progress notes starting with
September 10, 2020, and the discharge summary, supporting medical record documentation was not found
within the record.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay
for the inpatient services provided from September 7, 2020, to September 18, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment with Yervoy (J9228) and Nivolumab (J9299).
You asked the Plan to pre-approve Yervoy and Nivolumab. You say that the requested treatment is a medical
necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met
because the requested drugs have not been prescribed to treat a medically accepted indication.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer
drugs if they are medically accepted as safe and effective or appropriate for the particular use.
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 Yervoy and Nivolumab. Our reviewer
says that the requested treatment is not medically reasonable and necessary in this case. Our physician reviewer
found that the requested use of Yervoy and Nivolumab is not FDA-approved for the enrollee's diagnosis
because the enrollee's tumor has not been documented to express PD-L1 as determined by an approved test.
Furthermore, the use supported by one of the major drug compendia or by clinical research that appears in a
Medicare-approved medical journal.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Yervoy and Nivolumab have not been met. Therefore, we decided that the Plan
does not have to pre-approve treatment with Yervoy (J9228) and Nivolumab (J9299).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 9 additional home health physical therapy visits
(G0151).
You asked the Plan to pre-approve additional physical therapy visits. You say that the requested services are a
medical necessity for the enrollee. The Plan denied your request. The Plan says medical necessity rules for the
requested services have not been met.
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 additional physical therapy visits. Our
reviewer says that the requested services are not medically reasonable and necessary in this case. Our physician
reviewer found that there is no documentation that the additional 9 home health physical therapy visits are
required to effectively provide treatment, care, and/or services in order to improve the enrollee's level of
function, or to establish/perform a maintenance program to maintain the enrollee's level of function and/or
prevent deterioration. Records do not document any acute or unstable medical conditions or changes in
condition or treatment which would necessitate any further skilled home health physical therapy visits beyond
what have already been approved. No medical notes from the enrollee's treating physician are provided
documenting an order or need for additional home health skilled therapy services.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of additional physical therapy visits have not been met. Therefore, we decided that
the Plan does not have to pre-approve 9 additional home health physical therapy visits (G0151).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone marrow aspirate.
You asked the Plan to pre-approve bone marrow aspirate. 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 studies have not proven that this is helpful for the enrollee's condition.
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 bone marrow aspirate. Our reviewer
says that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found bone marrow aspirate is experimental in spine surgery. More research is needed to
show its safety and efficacy when used for bone graft material in surgery.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of bone marrow aspirate have not been met. Therefore, we decided that the Plan
does not have to pre-approve bone marrow aspirate.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair expandable controller, harness, and electronic connection device.

You asked the Plan to pre-approve expandable controller, harness, and electronic connection device. You say that the enrollee is nonambulatory and dependent on this wheelchair. The Plan denied your request. The Plan says the denial of authorization for these components is correct, because the enrollee's upper limb strength and function are adequate to be able to control the power options using their own switches.

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 expandable controller, harness, and electronic connection device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the approved power wheelchair has 3 power options of tilt, recline, and power elevating leg rests but the enrollee does not need to control the power options through a joystick. The enrollee's upper extremity strength and function support that the enrollee can control any power options through their own switches. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of expandable controller, harness, and electronic connection device have not been met. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair expandable controller, harness, and electronic connection device.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF care. You say that you have been experiencing pain and additional therapy is needed before you go home. The Plan denied your request. The Plan says the denial of authorization for SNF care is correct.

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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Step-Therapy
Decision: Favorable

We decided that the Plan has to pre-approve Eylea.

You asked the Plan to pre-approve Eylea. You say that this is medically necessary. The Plan denied your request. The Plan says that step therapy requirements have not been 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 Eylea. Our reviewer says that the requirements for coverage of Eylea have been met. Our physician reviewer found step therapy may only be applied to new prescriptions or administrations of Part B drugs for enrollees that are not actively receiving the affected medication. The documentation supports that the enrollee in this case is actively receiving Eylea. The enrollee received his first dose of Eylea on December 28, 2021. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Eylea have been met. Therefore, we decided that the Plan has to pre-approve Eylea.

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: 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 inpatient rehabilitation services are medically necessary for this enrollee. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. The enrollee can safely receive the necessary services in an alternate setting.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

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 complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Her comorbid conditions are stable and there are no acute or complex rehab nursing needs noted in the record. At the current functional level, the enrollee does not require intensive therapies, consisting of at least three hours of therapy per day at least five days per week with a multidisciplinary approach to daily therapy. While the enrollee may benefit from physical and occupational therapies. the enrollee's rehab needs can safely be met in an alternate and less intensive setting. Documentation does not support the necessity for admission to an IRF. 

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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (88305) provided on June 25, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is not supported.

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 88305 is "Level IV - Surgical pathology, gross and microscopic examination Abortion - spontaneous/missed Artery, biopsy Bone marrow, biopsy Bone exostosis Brain/meninges, other than for tumor resection Breast, biopsy, not requiring microscopic evaluation of surgical margins Breast, reduction mammoplasty Bronchus, biopsy Cell block, any source Cervix, biopsy Colon, biopsy Duodenum, biopsy Endocervix, curettings/biopsy Endometrium, curettings/biopsy Esophagus, biopsy Extremity, amputation, traumatic Fallopian tube, biopsy Fallopian tube, ectopic pregnancy Femoral head, fracture Fingers/toes, amputation, non-traumatic Gingiva/oral mucosa, biopsy Heart valve Joint, resection Kidney, biopsy Larynx, biopsy Leiomyoma(s), uterine myomectomy - without uterus Lip, biopsy/wedge resection Lung, transbronchial biopsy Lymph node, biopsy Muscle, biopsy Nasal mucosa, biopsy Nasopharynx/oropharynx, biopsy Nerve, biopsy Odontogenic/dental cyst Omentum, biopsy Ovary with or without tube, non-neoplastic Ovary, biopsy/wedge resection Parathyroid gland Peritoneum, biopsy Pituitary tumor Placenta, other than third trimester Pleura/pericardium - biopsy/tissue Polyp, cervical/endometrial Polyp, colorectal Polyp, stomach/small intestine Prostate, needle biopsy Prostate, TUR Salivary gland, biopsy Sinus, paranasal biopsy Skin, other than cyst/tag/debridement/plastic repair Small intestine, biopsy Soft tissue, other than tumor/mass/lipoma/debridement Spleen Stomach, biopsy Synovium Testis, other than tumor/biopsy/castration Thyroglossal duct/brachial cleft cyst Tongue, biopsy Tonsil, biopsy Trachea, biopsy Ureter, biopsy Urethra, biopsy Urinary bladder, biopsy Uterus, with or without tubes and ovaries, for prolapse Vagina, biopsy Vulva/labia, biopsy". 

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 services. Our reviewer says that the use of code 88305 is not supported by the records provided. Our reviewer found that the laboratory report documents hemorroids for the biopsy, however the report documents "large tubulovillous adenoma, inflamed overlying hemorrhoids, and polypoid mass." Documentation does not include what tissue was biopsied to confirm the correct pathology code. 

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 services have not been met. Therefore, we decided that the Plan does not have to pay for the services (88305) provided on June 25, 2021.