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

 We decided that the Plan does not have to pre-approve the Myopro device for the enrollee.  You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says medical studies have not proven that this device is helpful for treatment of the health problem.  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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found at this time, the requested robotic orthosis is not proven to be more beneficial for treatment of the enrollee's medical condition/function of hemiparesis after stroke than any available standard therapy such as conventional treatments for post stroke hemiparesis therapy including constraint induced movement therapy, conventional muscle strengthening, and botox for spasticity if needed. The requested device is not reasonable and necessary for the diagnosis or treatment of an illness or injury or  to improve the functioning of a malformed body member. The MyoPro is not known to be effective, based on scientific evidence, professional standards and expert opinion, in improving health outcomes in stroke patients. The MyoPro is not in widespread use based on scientific evidence. There is insufficient evidence in the literature that the MyoPro Orthosis will improve the long term outcomes for this enrollee, improve hemiparetic arm function, or be safe for long term use. There is insufficient evidence in the literature that this device will increase participation in bimanual activities.  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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Myopro device for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Tremfya.  You asked the Plan to pre-approve Tremfya. You say that the enrollee has a longstanding history of psoriasis. The Plan denied your request. The Plan says the drug is not covered under the Part B 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 Tremfya.     Benefits for Tremfya 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: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve dental services.  You asked the Plan to pre-approve the requested services. You say that you cannot chew your food due to the pain. The Plan denied your request. The Plan says the services are not 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.  The file shows that addition of a metal substructure, a precision attachment, and autologous blood concentrate products were requested. Although the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit.  The file shows that 11 teeth extractions were requested. The Plan has agreed to pre-approve 8 extractions. Your plan only covers 8 extractions per year. Additional extractions are not covered by your plan. Therefore, we decided that the Plan does not have to pre-approve dental services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Inogen One G4 portable oxygen concentrator
(E1392).
You asked the Plan to provide coverage for an Inogen One G4 oxygen concentrator. You say that this
equipment is medically necessary as the current unit (the Inogen One G3) is too heavy. The Plan denied your
request. The Plan says Medicare coverage criteria are not met. Maximus overturned the Plans denial. The Plan
requested a reopen and provided additional information.
The Plan stated that the IRE indicated the Inogen G4 portable oxygen concentrator, or an equivalent portable
oxygen concentrator of similar weight is medically necessary in this case because the current portable oxygen
concentrator (the Inogen G3) is heavier, and you state you are unable to carry it without discomfort and pain.
The Plan states your providers office confirmed that there have been no significant changes in your medical
condition and that your diagnoses of rheumatoid arthritis, lupus and joint pain have been stable since 2018.
Also, your current Inogen G3 portable oxygen concentrator weighs 4.8 lbs. (this is contrary to the
pulmonologist's claims that it weighs 8 pounds), compared to the Inogen G4 oxygen concentrator which
weighs 2.8 lbs.
It is the Plan's contention that a 2 lb. weight difference is insignificant and "similar" enough that the requested
device is not medically necessary for use in the home. It should also be mentioned, additional or duplicate
equipment is not covered for use outside of the home, and therefore, this would qualify as duplicate equipment
in the home which also is not covered by Medicare.
The Plan is correct in this case. The Plan must follow Medicare rules. The rules say Medicare covers
equipment only when it is reasonable and necessary for use in the home. If the requested equipment serves the
same purpose as equipment already available to you, it is not considered reasonable and necessary. The file
shows that you were using an Inogen One G3 prior to the appeal for an Inogen One G4. The Inogen One G3
serves the same purpose as the requested equipment. The weight difference between units is not significant
enough to make a difference for use in the home. There are no specific medical records that show you are
unable to lift the current equipment in the home. Therefore, we decided that the Plan does not have to provide
coverage for an Inogen One G4 portable oxygen concentrator (E1392).
Appeal type: Drugs
Decision: Favorable

 We decided that the Plan has to pre-approve administration of Entyvio every 6 weeks.  You asked the Plan to pre-approve administration of Entyvio every 6 weeks. You say that the increased frequency of the medication is medically reasonable and necessary. The Plan denied your request. The Plan says that it is not medically necessary for the drug to be administered every 6 weeks.  The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve administration of Entyvio every 6 weeks. Our reviewer says that the requested increase in frequency of Entyvio from every 8 weeks to every 6 weeks is medically reasonable and necessary. Our physician reviewer found that the patient is a male with ulcerative colitis. Entyvio was started due to flare on mesalamine only and was reporting positive response from Entyvio use. Rectal bleeding was recently noted, and Rowasa enema was started and was reported to be helping the bleeding and pain. However, bowel movements are still frequent (6 daily). Entyvio level was lower than optimal on testing and an increase in frequency of dosing was recommended by the treating physician. A request for Entyvio every 6 weeks was made. The documentation does support that Entyvio every 6 weeks is medically reasonable and necessary for the patient due to the fact that therapeutic levels are too low with the current frequency and that he is in a flare-up. An increase in frequency at least for the short-term is reasonable and necessary at this time. The documentation does support that Entyvio every 6 weeks is safe and effective for the patient. There was report of benefit without short-term side effects. Low levels were seen on serum level testing suggesting low risk of overdosing.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of administration of Entyvio every 6 weeks have been met. Therefore, we decided that the Plan has to pre-approve administration of Entyvio every 6 weeks.   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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of decitabine.

You asked the Plan to pre-approve decitabine. You say that decitabine is one of the approved regimens for the enrollee's condition. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because decitabine is not medically necessary for the enrollee's condition.

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 decitabine. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested use of decitabine. Our physician reviewer found decitabine is not Food & Drug Administration (FDA) approved for the enrollee's diagnosis. The requested use is not supported by one of the major drug compendia or by clinical research appearing 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 decitabine have not been met. Therefore, we decided that the Plan does not have to pre-approve use of decitabine.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the needle electromypgraphy and neuromuscular junction testing (95885 and 95937) provided on July 23, 2021.  You asked the Plan to pay for the needle electromyography and neuromuscular junction testing. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support the services billed.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.  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 needle electromyography and neuromuscular junction testing. Our reviewer says that CPT code 95885 does not meet criteria for billing or reimbursement consideration. The medical records provided do not document that a limited needle electromyography with nerve conduction was performed on July 23, 2021.  The medical records document that pedicle screw stimulations were performed which are not baseline nerve conduction studies, therefore this service cannot be verified. Our reviewer found CPT code 95937 does not meet criteria for billing or reimbursement consideration. The medical records submitted document Train of Four testing, which does not meet the coding definition of CPT 95937, therefore, this service cannot be verified. Also, there is no CPT code specific to Train of Four testing. It is inclusive to intraoperative neuromonitoring.  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 needle electromyography and neuromuscular junction testing have not been met. Therefore, we decided that the Plan does not have to pay for the needle electromypgraphy and neuromuscular junction testing (95885 and 95937) provided on July 23, 2021.
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 IRF care is medically necessary. The Plan denied your request. The Plan says rules for IRF care have not been met.  

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 patient was admitted for a stroke. Medical problems are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the patient has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. In conclusion, there is not a reasonable expectation that this patient 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 pre-approve a specialist office visit (99213) to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve a specialist office visit. You say that the patient was seen by this provider in the hospital and the provider had put stents in the lower right extremity. You also say that this patient needs to have a hospital and surgical follow-up with doctor. The Plan denied your request. The Plan says there are no continuity of care issues and there are par providers available. The Plan also says that the member has established care with a participating provider vascular surgeon.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.  The provider at issue in this case is not a network provider with the Plan. 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 an office visit. Our reviewer says that this does not meet criteria. Our physician reviewer found based on the medical records provided, there is no documentation showing that it is medically reasonable and necessary for the enrollee to continue seeing the out-of-network provider as opposed to an in-network provider. The records do not document that the enrollee's condition is of such complexity that an equally qualified and licensed in-network provider would not be able to provide an equivalent level of care 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 an office visit have not been met.   The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve a specialist office visit. Therefore, we decided that the Plan does not have to pre-approve a specialist office visit (99213) to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.  You asked the Plan to pre-approve the LTACH services. You say that the admission to an LTACH is medically necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically necessary.  The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.  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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found based on the documentation provided you appear to not be stable enough for transfer at this time. Acute care services can be safely administered at the current facility for the time being until treatment is completed and transfer to a lower level of care is more appropriate. You do not require services at the LTACH that are not already available at the current facility. There are no services at the LTACH that you require that are not already available and covered at the current facility.    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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Rhopressa.  You asked the Plan to pre-approve Rhopressa. You say that the medication is necessary. The Plan denied your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage.  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 Rhopressa.   Benefits for Rhopressa 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 pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

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 your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.

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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve computed tomography (CT) services.  You asked the Plan to pre-approve the CT scan. You say that the requested CT scan is medically necessary, as the enrollee has unintentionally lost weight. The Plan denied your request. The Plan says the records has not lost great than or equal to 10 pounds. The Plan says that the records do not show the results of a thorough workup that failed to reveal the cause of weight loss.  The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the CT scan. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the record indicates that the enrollee has a gastric ulcer for which he is being treated. The record indicates that the enrollee may have lost five pounds over a six-month period. The provided records do not indicate the medical necessity or reasonableness, as defined by Medicare rules, of the requested service.  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 CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve computed tomography (CT) services.