Persius/hicric huggingface dataset:
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 immunotherapy with Pembrolizumab is expected to
be better tolerated and can palliate the enrollee's current symptoms. The Plan denied your request. The Plan
says the enrollee does not meet the clinical criteria for coverage.
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
Keytruda is not medically reasonable and necessary for the enrollee. Our physician reviewer found the
requested use of Pembrolizumab (Keytruda) is not Food and Drug Administration (FDA)-approved for the
enrollee's diagnosis. Our reviewer found that the use is not supported by one of the major drug compendia or
by clinical research that appears in a CMS-approved medical journal. Our physician reviewer also found that
the use is not listed as not indicated, not supported or not recommended in any of the compendia.
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the IRF admission is medically necessary. The Plan denied your request. The Plan says the enrollee's medical conditions are stable, and do not require daily physician oversight. The Plan also says that the enrollee's care needs can be provided at a lesser level of care.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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. The enrollee's current medical status does not require intensive physician and nursing monitoring or management in an IRF. Our reviewer also found that the enrollee may benefit from additional physical therapy, but the documentation does not support that the enrollee's functional status requires this therapy on an intensive IRF level. 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 IRF admission and services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to preapprove fifteen additional physical therapy visits.
You asked the Plan to preapprove additional therapy visits. You say that the services are necessary. The Plan
denied your request. The Plan says fifteen additional physical therapy visits is not medically necessary.
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 preapprove additional 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 requested additional therapy is not generally accepted as
specific and effective therapy for the enrollee's condition beyond what was approved by the plan. The
documentation indicates the enrollee has had prior therapy. The records do not demonstrate that the unique
skills of a professional therapist are required to safely and effectively provide treatment, or that the services can
be safely and effectively performed only by a therapist, 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, and
the specialized skill, knowledge and judgment of a qualified therapist are not 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 additional therapy visits have not been met. Therefore, we decided that the Plan
does not have to preapprove fifteen additional physical therapy visits.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an additional four physical therapy visits for the enrollee.
You asked the Plan to pre-approve the additional visits. You say that this is medically necessary. The Plan denied your request. The Plan says the additional four visits are not medically reasonable or necessary.
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 additional 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 requested additional therapy is not generally accepted as specific and effective therapy for the enrollee's condition beyond what was approved by the plan. The documentation indicates prior therapy. The records do not demonstrate that the enrollee's functional level needs the unique skills of a professional therapist to safely and effectively provide treatment, or that the services can be safely and effectively performed only by a therapist, 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, and the specialized skill, knowledge and judgment of a qualified therapist are not 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 additional visits have not been met. Therefore, we decided that the Plan does not have to pre-approve an additional four physical therapy visits for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a stepping stool with handrails.  

You asked the Plan to pre-approve a stepping stool with handrails. You say that this is necessary to help you get into the tub. The Plan denied your request. The Plan says this item is not covered by Medicare as it is not medical in nature.  

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.       

The item at issue in this appeal 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 a stepping stool with handrails.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services provided on July 13, 2021 by an out-of-network (OON) provider.  

You asked the Plan to pay for the laboratory services provided by an OON provider. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network care.  

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to 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 the laboratory services provided on July 13, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

 We decided that the Plan has to reimburse additionally for the outpatient services provided by a participating provider from October 14, 2020 to January 14, 2021.  

You asked the Plan to reimburse additionally for the outpatient services provided by a participating provider. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says that additional reimbursement is not covered.  

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.  

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Specifically, it is the plan's responsibility to show that its decision to deny coverage is correct. Records from a plan provider are considered to be within the control of the plan. In cases where the plan has not supplied records from a plan provider that are critical to its decision, we may properly find that the denial is not appropriate or justifiable. Enrollees should not be penalized for a plan's failure to obtain records that are within the plan's control. The participating provider's payments received by the enrollee are considered within the Plan's control. We find that the Plan has not provided enough information to justify the denial of additional reimbursement. Therefore, we decided that the Plan has to reimburse additionally for the outpatient services provided by a participating provider from October 14, 2020 to January 14, 2021.   

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: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an additional 8,660 units of non-waterproof tape (A4450).  

You asked the Plan to pre-approve additional units of non-waterproof tape. You say that additional tape beyond what the Plan has approved is medically necessary. The Plan denied your request. The Plan says there is no need for additional tape beyond what has been already approved.  

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 additional units of non-waterproof tape. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the patient is a 71 year old female who underwent surgical debridement in 2017 for a non-healed sacral ulcer. She reports to use non-waterproof tape regularly. It is reported that the patient requires wound dressing changes every 1-3 days. The wound was approximated as 2.32 sq cm. Based on this information, the approved 540 rolls should be more than enough to meet her need. Therefore, the requested 8,660 roles of tape exceed the patient's needs.   

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 units of non-waterproof tape have not been met. Therefore, we decided that the Plan does not have to pre-approve an additional 8,660 units of non-waterproof tape (A4450).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the vision office visit services provided on August 19, 2021, by an OON provider.  

You asked the Plan to pay for the vision office visit services. You say that the Plan must reimburse non-contract providers. 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. Therefore, we decided that the Plan does not have to pay for the vision office visit services provided on August 19, 2021, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the physician services provided on July 8, 2021 by an out-of-network (OON) provider.  

You asked the Plan to pay for the physician services provided by an OON provider. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network care.  

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to 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 the physician services provided on July 8, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the two crowns (D2740 x2) and two core buildups, including any pins when required (D2950 x2) provided on January 15, 2020.  You asked the Plan to pay for the crowns and core buildups. You say that at the time of service your provider advised you that there was no coverage for these procedures. You also say that thinking they were knowledgeable in this matter, you did not pursue this. The Plan denied your request. The Plan says this claim was filed outside of the timely filing period.  The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service.  The record shows that a claim for the crowns and core buildups was not filed until July 21, 2021. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the two crowns (D2740 x2) and two core buildups, including any pins when required (D2950 x2) provided on January 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the 2 Mode Cleaner Box for tubes/hose/filters/mask with tube connector and ResMed Climate Line Air Heated Tube for ResMed AirSense 10 & AirCurve 10 purchased October 22, 2021.  

You asked the Plan to pay for the cleaner box and water tube for a Continuous Positive Airway Pressure (CPAP) machine. You say that you feel these items should be covered under your Flex Benefits. The Plan denied your request. The Plan says these items are not listed under the Plan's Flex Benefit's eligible items  

The Plan must follow Medicare rules. Medicare rules say that your Flex benefit can be used for non-Medicare healthcare expenditures.          

We looked at the file and Medicare rules. CPAP accessories are covered by Medicare; therefore they are not eligible for coverage under the Flex benefit. Therefore, we decided that the Plan does not have to pay for the 2 Mode Cleaner Box for tubes/hose/filters/mask with tube connector and ResMed Climate Line Air Heated Tube for ResMed AirSense 10 & AirCurve 10 purchased October 22, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pay for physical therapy services provided by a physical therapy assistant on April 28, 2021.    You asked the Plan to pay for the physical therapy services. You say that plans are required to pay non-contracted providers at the preferred provider rate when the services are not available from preferred providers in the service area. You say that the in-network benefits should be honored, and the claim processed for payment. The Plan denied your request. The Plan says the records do not support the service billed.  The Plan must follow Medicare rules. Medicare rules say that the services of a physical therapy assistant (PTA) shall not be billed as services incident to a physician/non-physician practitioner's (NPP) service, because they do not meet the qualifications of a therapist.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the physical therapy services have not been met. Specifically, the billing provider is a nurse practitioner, and not a licensed therapist. As such, PTA services cannot be paid incident to this provider's professional services. Therefore, we decided that the Plan does not have to pay for physical therapy services provided by a physical therapy assistant on April 28, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the SelectMDx testing provided on January 12, 2021.  

You asked the Plan to pay for the testing services. You say that the test identifies prostate cancer prior to biopsy. The Plan denied your request. The Plan says the clinical utility and validity are not established.  

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 the testing services. Our physician reviewer found that the 2-gene based urine assay, which is optimized for biopsy naive patients with serum prostate specific antigen (PSA) less than 10 ng/ml, demonstrated high sensitivity and negative predictive value to detect clinically significant prostate cancer. In this case, the enrollee's PSA score was greater than 10. The records do not show that the tests results would improve the outcome or change the treatment of the enrollee. The testing services were not medically reasonable or necessary 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 the testing services have not been met. Therefore, we decided that the Plan does not have to pay for the SelectMDx testing provided on January 12, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve facet joint injections.  

You asked the Plan to pre-approve facet joint injections. 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 record does not show that the enrollee's pain is localized in the lower back and does not travel to other areas of the body.  

The Plan follows Medicare rules. Medicare rules state that facet joint interventions may be covered under certain circumstances.  

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 facet joint injections. Our reviewer says that the enrollee does not meet the Medicare criteria for facet joint interventions. Our physician reviewer found the enrollee has low back pain with associated radiculopathy. Therefore, the requested procedure is 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 facet joint injections have not been met. Therefore, we decided that the Plan does not have to pre-approve facet joint injections.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for the outpatient behavioral health services provided from August 10, 2021 to September 7, 2021.  You asked the Plan to pay for the outpatient behavioral health services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says a licensed mental health counselor is not eligible to enroll in the Medicare program per Medicare guidelines.  The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program.  We looked at the case file and Medicare rules. In this case, the provider is a licensed mental health counselor and does not qualify as a mental health provider eligible for payment per Medicare guidelines. Therefore, we decided that the Plan does not have to pay for the outpatient behavioral health services provided from August 10, 2021 to September 7, 2021.