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

 We decided that the Plan does not have to pre-approve SNF care.  You asked the Plan to pre-approve SNF care. You say that the enrollee has been medically ready since the beginning of December. The Plan denied your request. The Plan says the stay is not medically necessary.  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 the enrollee has stabilized medically and is ready for discharge from the hospital. The enrollee does not require skilled nursing and/or skilled therapy services on a daily basis. The enrollee is medically stable and can receive further rehabilitation services at a lower level of care. Although further rehabilitation services would be appropriate to improve function, as a practical matter, the intermittent skilled services can be provided at a lower level of care than a SNF. The enrollee does not have any parental medication; complex wound care or nutrition given via a feeding tube. The enrollee is medically stable without any acute exacerbations of chronic medical problems. The enrollee's physical function is at or near their baseline and they can receive services at a lower level of care. Admission to a SNF for inpatient skilled rehabilitation services is not medically necessary.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140), first intraoral periapical x-ray (D0220), and resin-based composite (D2393) for tooth # 18 provided on August 3, 2021.  You asked the Plan to pay for the problem focused limited oral evaluation, first intraoral periapical x-ray, and resin-based composite. You say that you had an existing tooth filled and were advised by the Plan that half of the procedure would be covered because the treating provider was out-of-network. The Plan denied your request. The Plan says these services are not covered expenses under your dental plan. The Plan also says that a resin-based composite (D2393) for tooth # 18 was billed, but the records show tooth # 18 has been extracted, and this service cannot be covered.  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 pay for the problem focused limited oral evaluation (D0140), first intraoral periapical x-ray (D0220), and resin-based composite (D2393) for tooth # 18 provided on August 3, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Austedo (J8499).  You asked the Plan to pre-approve Austedo. You say that the requested drug is medically necessary for the enrollee. 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 Austedo (J8499).    Benefits for Austedo 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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the insertion of a Vertiflex Superion device at spinal level L3-L4.  You asked the Plan to pre-approve the insertion of a Vertiflex Superion device. You say that the medical records provided support the medical necessity of the requested procedure. The Plan denied your request. The Plan says the requested procedure is not reasonable or necessary.  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 insertion of a Vertiflex Superion device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental. More research is needed to show safety and efficacy of the device.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the insertion of a Vertiflex Superion device have not been met. Therefore, we decided that the Plan does not have to pre-approve the insertion of a Vertiflex Superion device at spinal level L3-L4.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a specialist office visit provided on August 2, 2021.  You asked the Plan to waive the copayment for the specialist office visit. You say that the provider is a level 1 specialist. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.  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 $45 copayment for each specialist visit with a physician that is not identified as a level 1 provider.   The file shows that a search the Plan provider directory does not identify the provider as a level 1 physician. Therefore, you have been asked to pay a $45 copayment for the specialist office visit. Specialist office visits fall within the Physician/Practitioner Services, Including Doctor's Office Visits 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 copayment for a specialist office visit provided on August 2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a heavy-duty walker and related accessories.  You asked the Plan to pre-approve the requested walker. You say that you are at risk of falling. The Plan denied your request. The Plan says coverage criteria have not been met.  The Plan must follow Medicare rules. Medicare rules say that heavy-duty walkers are only covered under certain medical indications.    The file shows that a heavy-duty walker with a wire basket and cup holder were requested. We looked at the file and Medicare rules. The records provided do not indicate that you meet the weight requirements for the requested walker. Enhancement accessories, such as the basket and cup holder are non-covered. Based on this information, we decided that Medicare rules for coverage of the requested walker have not been met. Therefore, we decided that the Plan does not have to pre-approve a heavy-duty walker and related accessories.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Oxycodone-Acetaminophen.  You asked the Plan to pre-approve Oxycodone-Acetaminophen. You say that the requested drug is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says this drug is not covered under the enrollee's medical benefit.  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 Oxycodone-Acetaminophen.   Benefits for Oxycodone-Acetaminophen 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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the radiofrequency ablation (RFA) of the genicular nerves provided on June 1, 2021.  You asked the Plan to pay for the RFA procedure. You say that it is felt that this should be reimbursed as a medically necessary procedure. The Plan denied your request. The Plan says this procedure is investigational and not covered.  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 RFA procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found genicular nerve blocks and genicular nerve radiofrequency ablation are considered investigational and not medically necessary for the treatment of chronic knee pain, including, but not limited to any of the following:  degenerative joint disease; osteoarthritis of the knee; as a treatment prior to knee replacement; as a treatment following knee replacement; or as a treatment for individuals who are not candidates for knee replacement 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 the RFA procedure have not been met. Therefore, we decided that the Plan does not have to pay for the radiofrequency ablation (RFA) of the genicular nerves provided on June 1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a continuous positive airway pressure (CPAP) device and accessories.  You asked the Plan to pre-approve CPAP equipment. You say that this equipment is medically necessary for your condition. The Plan denied your request. The Plan says no medical records were delivered to support the requested equipment.  The Plan must follow Medicare rules. The rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment.   We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Specifically, there were no medical records provided in this case. Without the medical records, we cannot review to see if the services are medically necessary. Based on this information, we decided that Medicare rules for coverage of CPAP equipment have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous positive airway pressure (CPAP) device and accessories.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a neurobehavioral status exam.  You asked the Plan to pre-approve a neurobehavioral status exam. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.  The Plan follows Medicare rules. Medicare rules say that neurobehavioral status exams are only covered for certain indications.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a neurobehavioral status exam. Our reviewer says that the documentation does not support that the requested services are medically reasonable or necessary. Our physician reviewer found the enrollee has shown impairment in functioning as documented. The enrollee has been showing difficulty with cognitive issues as outlined using the interpretation. There was no documentation that justifies the extra amount of time in the testing and assessment. Based on review the records provided and the information provided this enrollee does not meet the criteria for additional neuropsychological testing beyond which is approved by LCD L33632 based on the enrollee's clinical history and documentation presented.  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 neurobehavioral status exam have not been met. Therefore, we decided that the Plan does not have to pre-approve a neurobehavioral status exam.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Gel-One.  You asked the Plan to pre-approve Gel-One. You say that this drug is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says step therapy criteria 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 Gel-One. Our reviewer says that the requested drug is not medically reasonable and necessary based on Medicare rules. Our physician reviewer found that the record indicates that you have osteoporosis of the knee. The requested medication is a new start. The provided records do not indicate that you have tried and failed the plan's preferred step one alternative. The record does not indicate that you have a contraindication to or would have an adverse effect from the Plan's preferred step one alternative. The elements of the coverage criteria are not satisfied. The requested service cannot be recommended.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Gel-One have not been met. Therefore, we decided that the Plan does not have to pre-approve Gel-One.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve IRF admission and services.  You asked the Plan to pre-approve IRF care. You say that you need acute rehabilitation to increase strength and endurance to resume your normal daily (activities). You say that being in nursing home is not the right setting to do this as you feel that acute IRF offers better facilities and staff to encourage you to reach your goal of independent living. The Plan denied your request. The Plan says you do not meet the Medicare criteria for admission to an IRF, and a lower level of care might be appropriate.  
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 that the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for metabolic encephalopathy, hypoglycemia, and acute kidney injury. Your medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While you have a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. 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 IRF admission and services.
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 requested admission is medically necessary. The Plan denied your request. The Plan says the requested IRF 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 enrollee does not have complex nursing or rehabilitation needs. The reviewer found that while the enrollee has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. The reviewer also found that there is not a reasonable expectation that the enrollee 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. Specifically, the file shows that there is no documentation of a need for an intensive rehabilitation program. 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 pre-approve ultrasound-guided sclerotherapy of the right leg in addition to ultrasound guided sclerotherapy of the left leg and Varithena of the left leg.  You asked the Plan to pre-approve ultrasound-guided sclerotherapy of the right leg in addition to ultrasound guided sclerotherapy of the left leg and Varithena of the left leg. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.  The Plan follows Medicare rules. Medicare rules say that treatment of varicose veins is only covered for certain indications.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve ultrasound-guided sclerotherapy of the right leg in addition to ultrasound guided sclerotherapy of the left leg and Varithena of the left leg. Our reviewer says that the documentation does not support that the requested services are medically reasonable or necessary. Our physician reviewer found the enrollee has a history of low back pain and herniated disc complaining of bilateral significant pain, heaviness and fatigue, and intermittent claudication despite duplex demonstrating closure of both the above and below the knee greater saphenous veins, closure of the small saphenous vein, no reflux demonstrated on the right, and reflux noted in a single isolated tributary vein measuring less than 4 mm in diameter. Although no reflux is noted on the right, the documented procedure treatment plan is ultrasound-guided sclerotherapy of the right leg in addition to ultrasound guided sclerotherapy of the left leg and Varithena of the left leg. Coverage criteria requires that the vein to be treated is greater than four mm in diameter. The documentation demonstrates that the vein to be treated is less than four centimeters in diameter. Therefore, the enrollee does not meet criteria for the requested 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 ultrasound-guided sclerotherapy of the right leg in addition to ultrasound guided sclerotherapy of the left leg and Varithena of the left leg have not been met. Therefore, we decided that the Plan does not have to pre-approve ultrasound-guided sclerotherapy of the right leg in addition to ultrasound guided sclerotherapy of the left leg and Varithena of the left leg.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Keytruda (J9271).  You asked the Plan to pre-approve Keytruda. You say that the enrollee is currently receiving folinic acid, fluorouracil, and oxaliplatin (FOLFOX) chemotherapy every 14 days. You also say that the requested drug is to be added to their current treatment. The Plan denied your request. The Plan says the requested drug is not approved by the Food and Drug Administration (FDA) for the enrollee'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 Keytruda. Our reviewer says that the requested drug Keytruda is not medically necessary. Our physician reviewer found the provided documentation indicates that the request is for Keytruda to be added to the enrollee's current regimen of folinic acid, fluorouracil, and oxaliplatin (FOLFOX). The reviewer found that while the requested drug is approved for the enrollee's diagnosis, it is not approved by the FDA as an addition to a FOLFOX regimen.  The reviewer also found that it is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal (see appendix for list of CMS-approved journals). Therefore, the reviewer found that the requested drug 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 Keytruda have not been met. Specifically, the file shows that the requested drug is not FDA-approved for the enrollee's diagnosis when being added to a to FOLFOX regimen chemotherapy. Therefore, we decided that the Plan does not have to pre-approve Keytruda (J9271).