Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the fluid flow or fluid gf, 1 cc (CPT code Q4206).
You asked the Plan to pre-approve the service. You say that you have significant pain in the left knee, and you
are not a candidate for knee replacement due to your age. You state you have fallen several times, and you are
trying to do everything possible to maintain quality of life, decreased pain, and get back on a walker safely.
The Plan denied your request. The Plan says a review of the current medical literature indicates that this service
is considered experimental and investigational. The Plan states it is not identified as widely used and generally
accepted for the proposed use as reported in nationally recognized peer-reviewed medical literature published
in the English language. The Plan states the Medicare criteria for reasonable and necessary are not met, as it
has not been shown to be safe and effective in long term studies, and there is a lack of evidence to support the
clinical efficacy of this product.
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 service. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found the review has determined that a review of the current medical literature indicates that this
service is considered experimental and investigational. The treatment it is not identified as widely used and
generally accepted for the proposed use as reported in the peer-reviewed medical literature.
The Plan states the Medicare criteria for reasonable and necessary are not met, as it has not been shown to be
safe and effective in long term studies, and there is a lack of evidence to support the clinical efficacy of this
product. The items/services at issue in this case are not medically reasonable or necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the service have not been met. Therefore, we decided that the Plan does not
have to pre-approve the fluid flow or fluid gf, 1 cc (CPT code Q4206).
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 the service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary.  The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described 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 your medical conditions are stable and there are no complex nursing or rehabilitation needs. While you may have a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program.  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. Specifically, medically necessary services can be obtained in a lower level of care. This means admission into an IRF is not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve pembrolizumab (Keytruda).
You asked the Plan to pre-approve Keytruda. You say that the enrollee is unable to tolerate Taxanes due to
neuropathy. The Plan denied your request. The Plan says the enrollee does not have an FDA-approved
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 Keytruda. Our physician reviewer
found that the requested use of Keytruda is not FDA-approved for the enrollee's diagnosis. The use is not
supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical
journal. The requested use is not listed as not indicated, not supported or not recommended in any of the
compendia. The documentation does not 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 Keytruda have not been met. Therefore, we decided that the Plan does not have
to pre-approve pembrolizumab (Keytruda).
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for a computed tomography (CT) scan provided on May 27, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the CT scan. You say that the CT scan was a covered benefit which means no authorization was required. You say the service was medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.  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 did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. The records provided for review do not show that the service at issue was urgent or emergent. Therefore, we decided that the Plan does not have to pay for a computed tomography (CT) scan provided on May 27, 2021, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of Euflexxa.
You asked the Plan to pre-approve Euflexxa. You say that you are appealing this denial. The Plan denied your
request. The Plan says the denial of authorization for this drug is correct, because the Plan requires a trial of
Orthovisc, Synvisc, or Synvisc One before they will approve Euflexxa.
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 Euflexxa. Our reviewer says that the
enrollee does not meet the Medicare criteria for the requested use of Euflexxa. Our physician reviewer found
the enrollee has not tried and failed the Plan's preferred drugs of Orthovisc, Synvisc, or Synvisc One. The
records do 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 Euflexxa have not been met. Therefore, we decided that the Plan does not have
to pre-approve use of Euflexxa.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an adjustment of complete maxillary denture (D5410), reline complete maxillary denture (D5780), cone beam CT capture (D0367), and a surgical stent (D5982) to be provided by an out-of-network provider.  You asked the Plan to pre-approve dental services. You say that these services are medically necessary. The Plan denied your request. The Plan says the requested dental services are not covered benefits.  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 an adjustment of complete maxillary denture (D5410), reline complete maxillary denture (D5780), cone beam CT capture (D0367), and a surgical stent (D5982) to be provided by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), complete series x-ray (D0210), and full mouth debridement (D4355) provided from September 23, 2021, to September 24, 2021, by an out of network dentist.  You asked the Plan to pay for the dental services. You say that you were advised by a plan representative in August 2021 that you could go to any provider, and it would be equally covered whether the provider is in or out of network. You say that you were not able to contact the in network provider and therefore went to an out of network provider. You also say that you received a bill for $554. The Plan denied your request. The Plan says there were no calls made to the customer service department prior to receiving the services regarding the dental benefits. The Plan also says that since the provider was out of network, the difference of billed amount and amount the plan paid became your responsibility.  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 and the services are listed as covered, out of network providers may bill you for any amount greater than what the plan pays.   Procedure Code Billed Amount Allowed Amount Difference Plan Paid Your Responsibility D0150 $120 $36 $84 $36 $84 D0210 $187 $80 $107 $80 $107 D4355 $245 $73 $172 $73 $172 TOTAL:     $363  Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), complete series x-ray (D0210), and full mouth debridement (D4355) provided from September 23, 2021, to September 24, 2021, by an out of network dentist.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve methotrexate 2.5mg tablets.  You asked the Plan to pre-approve the methotrexate tablets. You say that this is a medically necessary treatment. The Plan denied your request. The Plan says this oral drug is not covered by Medicare 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 methotrexate 2.5mg tablets.   Benefits for the methotrexate tablets 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: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve foot orthotics.  You asked the Plan to pre-approve foot orthotics. You say that these are medically necessary for your condition. The Plan denied your request. The Plan says this item is not a covered benefit.  Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.    Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve epidermal inclusion cyst excision left posterior scalp for
the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your
request. The Plan says the records do not support an indication of malignancy or infection.
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 services. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found the documentation does not support that the enrollee in this case has a covered indication for excision of
the epidermal inclusion cyst. The cyst has intermittently drained white cheesy material since then. The cyst has
never been infected. There is no documentation of pain, bleeding, or change in appearance of the cyst.
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 epidermal inclusion cyst excision left posterior scalp for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Restasis.  You asked the Plan to pre-approve Restasis. You say that the enrollee has been using this medication for years with relief. The Plan denied your request. The Plan says the requested drug is considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the requested drug is not covered under Medicare 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 Restasis.   Benefits for Restasis 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: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the acute inpatient hospital care provided beginning on December 8, 2021.  You asked the Plan to pay for acute inpatient hospital care. You say that your heart rate had been 150 for two days and you had to be monitored to make sure you did not have a blood clot. The Plan denied your request. The Plan says based on Medicare guidelines, your request for approval of inpatient hospital admission for December 8, 2021, to December 9, 2021, does not meet the requirements for approval.    The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.   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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found that based on the documentation prior to and at the time of admission, there was insufficient indication that there was a complication related to the atrial fibrillation, and it spontaneously converted and could be managed at a lower level of care. There was no indication from the provided documentation that you would require hospital care that would likely cross 2 midnights.   We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided beginning on December 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an over the bed table.  You asked the Plan to pre-approve an over the bed table. You say that an over bed table is medically necessary. The Plan denied your request. The Plan says this item is not covered by Medicare.  The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  Self-help devices are not covered. An over the bed table is a self-help device. This item does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve an over the bed table.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a push wheelchair for the enrollee.  You asked the Plan to pre-approve a push wheelchair. You say that the enrollee resides in a facility and requires this equipment. The Plan denied your request. The Plan says Medicare coverage criteria are not met.  The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home. The records show that a push wheelchair is being requested for use in a SNF or hospital. Therefore, we decided that the Plan does not have to pre-approve a push wheelchair for the enrollee.   The IRE does not have jurisdiction over Medicaid benefits. If the enrollee is dual eligible, the enrollees Medicaid representative should be contacted for possible coverage of this equipment.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided the Plan does not have to pre-approve a replacement Group 2 Power Wheelchair for the enrollee. You asked the Plan to pre-approve this equipment. You say that the enrollee has used a power wheelchair for 6 years and requires a new one. The Plan denied your request. There is no completed form from the Department of Public Welfare (DPW) with a formal seating evaluation. The Plan says no documentation was provided to show the actual age of the current equipment or if it can be repaired. Insufficient medical records and evaluation records were provided to support the request for this power wheelchair. In addition, this enrollee is dual eligible. It is not clear if this is being submitted under the enrollees Medicare or Medicaid benefit.  The Plan follows Medicare rules. Medicare rules say that a power wheelchair will not be covered if the patient does not have mobility deficit that impairs their participation in daily activities in the home. Replacement equipment is only provided when the proper age of the equipment is determined or if the equipment is determined to not be repairable by a durable medical equipment provider.   This request lacks the required age and repair issues with the current equipment, appropriate seating evaluation, and clarification as to which benefit (Medicare or Medicaid) the equipment is being requested under. The Plan provided documentation to show your office was contacted several times to request and/or complete this process and no response was given to the Plan. Therefore, we decided that the Plan does not have to pre-approve a replacement Group 2 Power Wheelchair for the enrollee.   Please note that our decision is only about Medicare benefits. Maximus does not have jurisdiction regarding Medicaid benefits. Please contact the Plan to find out how to file an appeal of the denial of Medicaid benefits.
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 your knees are locked up. You say that you are not
getting the therapy you need. You also say that acute inpatient rehabilitation is the level of therapy that is
needed. The Plan denied your request. The Plan says the requested admission is not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described 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 provided documentation indicates you have no complex nursing or
rehabilitation needs. The reviewer found that while you have a need for rehabilitation therapy, there is no
documentation of a need for an intensive rehabilitation program. The reviewer found there is not a reasonable
expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy
program provided in 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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office visit provided on August 30, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the office visit. You say that the service was medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.  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 did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. The records provided for review do not show that the service at issue was urgent or emergent. Therefore, we decided that the Plan does not have to pay for the office visit provided on August 30, 2021, by an out-of-network (OON) provider.