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

We decided that the Plan does not have to pre-approve a portable home ventilator.

You asked the Plan to pre-approve a portable home ventilator. You say that a ventilator is medically necessary. The Plan denied your request. The Plan says that the request for a home mechanical ventilator set in AVAPS mode that could be delivered by BiPAP is not covered.

The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. 

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 portable home ventilator. Our reviewer says that a portable home ventilator is not medically reasonable and necessary. You have chronic respiratory failure and is oxygen-dependent.
The provided records do not show that you have tried and failed BiPAP with AVAPS which may be most appropriate for you based on the recent hospital treatment response. Our physician reviewer found that your condition does not meet Medicare criteria for a portable home ventilator. 

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 portable home ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a portable home ventilator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a collapsible walker with wheels to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve walker. You say that there is no in-network provider in your city. The Plan denied your request. The Plan says the denial of authorization for this item is correct, because this provider is out-of-network with the Plan and a walker can be provided by an in-network equipment supplier.
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 requested provider in this case is not a network provider with the Plan. 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 these items/services. Therefore, we decided that the Plan does not have to pre-approve a collapsible walker with wheels to be provided by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the fixed with air transport (A0430), the fixed wing air mileage, per statute mile, (A0435), and routine disposable supplies (A0398) provided on June 20, 2019.
You asked the Plan to pay for the air ambulance services. You say that the enrollee was transported to the nearest facility for services that were not available at the sending facility. The Plan denied your request. The Plan says the air transportation services were not medically necessary.
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your medical condition is such that transportation by ground ambulance is not appropriate. 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 air ambulance services. Our reviewer says that the air ambulance services are not medically necessary. Our physician reviewer found the provided documentation indicates that at the time of transport, the enrollee was hemodynamically stable. The documentation supports that the enrollee suffered from an illness or injury that contraindicates transportation by any means other than ambulance. The documentation did not support that the enrollee's condition was such that the time needed to transport the enrollee by ground, or the instability of transportation by ground, posed a threat to the enrollee's survival or seriously endangered the enrollee's health. Therefore, the reviewer found that the air ambulance services were 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 air ambulance services have been met. Specifically, the file indicates that that the enrollee's condition was not such that the time needed to transport the enrollee by ground, or the instability of transportation by ground, posed a threat to the enrollee's survival or seriously endangered the enrollee's health. Therefore, we decided that the Plan does not have to pay for the fixed with air transport (A0430), the fixed wing air mileage, per statute mile, (A0435), and routine disposable supplies (A0398) provided on June 20, 2019
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM).
You asked the Plan to pre-approve the requested CGM. You say that you meet the criteria for this because you do use insulin. You take 30 units at bedtime and are upset that this device is now being denied. The Plan denied your request. The Plan says you do not meet the Medicare criteria for coverage of a CGM device.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan.
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections requiring frequent adjustment based on blood sugar values. Based on this information, we decided that Medicare rules for coverage of the requested CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Cyramza (ramucirumab) for use with approved Folinic Acid/Fluorouracil/Irinotecan (FOLFIRI).
You asked the Plan to pre-approve the Cyramza. You say that this drug should be attempted due to progression with the use of Avastin. The Plan denied your request. The Plan says this cannot be approved as it is not proven to be safe and effective after a prior trial of FOLFIRI with Avastin.
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 the Cyramza. Our reviewer says that the requested use of this drug is not shown to be medically reasonable and necessary. Our physician reviewer found the enrollee has colon cancer with recent progression after treatment with FOLFIRI and Avastin. Request is to trial Cyramza in place of Avastin. Per The Lancet Oncology medical journal, the use of Cyramza with FOLFIRI is only approved for patients who have not used FOLFIRI in the past.
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 Cyramza have not been met. Therefore, we decided that the Plan does not have to pre-approve Cyramza (ramucirumab) for use with approved Folinic Acid/Fluorouracil/Irinotecan (FOLFIRI).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (UroVysion testing) provided to the enrollee on February 8, 2021.
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. The Plan says this is not a Medicare benefit for the diagnosis listed on the claim.
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. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the UroVysion Bladder Cancer Kit is designed to detect aneuploidy for chromosomes 3, 7, 17, and loss of the 9p2l locus via fluorescence in situ hybridization (FISH) in urine specimens from persons with hematuria suspected of having bladder cancer. Results from the UroVysion Kit are intended for use, in conjunction with and not in lieu of current standard diagnostic procedures, as an aid for initial diagnosis of bladder carcinoma in patients with hematuria and subsequent monitoring for tumor recurrence in patients previously diagnosed with bladder cancer. The case file does not contain clinical records documenting standard diagnostic procedures for the initial diagnosis of bladder carcinoma, or a previous diagnosis of bladder cancer. 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 have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services (UroVysion testing) provided to the enrollee on February 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the autonomic function testing provided through the TM
Flow device on February 5, 2021.

You asked the Plan to pay for the autonomic function testing. You say that this is medically necessary. The
Plan denied your request. The Plan says this is not coded correctly and cannot be covered.

The Plan must follow Medicare rules. Medicare rules say that autonomic function testing is only covered when
there are signs/symptoms of autonomic neuropathy after other potential causes for the symptoms are ruled out.

In this case, there is no documentation of any sign or symptom of autonomic neuropathy. The enrollee is being
treated by the rendering provider for diabetic peripheral neuropathy, which is pain/numbness/tingling in the
legs and feet. There is no description of any symptom affecting involuntary bodily functions. There is also no
documentation that the results are being used in clinical decision-making or patient management, as the results
of this testing are not documented in the record. Therefore, we decided that the Plan does not have to pay for
the autonomic function testing provided through the TM Flow device on February 5, 2021.
Appeal type: Outpatient Therapies
Decision: Favorable

We decided that the Plan has to waive the copayment for the voice analysis provided on April 20, 2021.
You asked the Plan to waive the copayment for the voice analysis. You say that you never asked for speech
therapy and shouldn't be billed twice for one visit. The Plan denied your request. The Plan says that the $40
copayment for speech therapy services applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your
contract with the Plan says that the $45 specialist copayment includes consultation, diagnosis, and treatment by
a specialist.
The Plan says you must pay a separate $40 copayment for the voice analysis. Based on the Plan contract,
however, you cannot be asked to pay more than $0 for the voice analysis. The voice analysis is considered a
physician service that would be included in the $45 specialist copayment. Therefore, we decided that the Plan
has to waive the copayment for the voice analysis provided on April 20, 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that 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 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 his physical function is at or near his baseline and he 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 skilled nursing facility (SNF) care.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Stelara.
You asked the Plan to pre-approve Stelara. 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.
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 Stelara. Our reviewer says that the medication is not medically necessary. Our physician reviewer found the requested medication is a new start. The provided records do not indicate that the enrollee has tried and failed the plan's preferred step one alternative. The record does not indicate that the enrollee has a contraindication to or would have an adverse effect from the plan's preferred step one alternatives. 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 Stelara have not been met. Therefore, we decided that the Plan does not have to pre-approve Stelara.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Botox.
You asked the Plan to pre-approve Botox. 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 follows Medicare rules. Medicare rules say that off-Label indications for onabotulinumtoxinA
(Botox) may be considered medically reasonable and necessary when specific criteria are met.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve Botox. Our reviewer says that the
services are not medically necessary. Our physician reviewer found in this case; the record indicates that the
enrollee has gastroparesis. This is an off-label indication. Gastroparesis is not an indication for which coverage
is available under the local coverage criteria. The elements of the coverage criteria are not satisfied. The
requested service is not 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 Botox have not been met. Therefore, we decided that the Plan does not have to
pre-approve Botox.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Evenity.
You asked the Plan to pre-approve Evenity. You say that you want to start treatment as soon as possible. The Plan denied your request. The Plan says that the use of this drug in your case requires that the drug be used for postmenopausal osteoporosis in a member at high risk for fracture or failed or intolerant to other available osteoporosis therapy.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved 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 Evenity. Our reviewer says that Evenity is not medically reasonable and necessary. Evenity is not FDA-approved for your diagnosis. Its use in this case 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 found that your condition does not meet criteria for Evenity.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Evenity have not been met. Therefore, we decided that the Plan does not have to pre-approve Evenity.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that you have issues with your wounds/ulcers and that the lab work came back abnormal. The Plan denied your request. The Plan says the guidelines for coverage of continued SNF care have not been met. The Plan say that the therapy needed can be received at a different setting.
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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does have documented skilled nursing needs, in the form of daily wound care for multiple wounds. The enrollee does have documented skilled therapy needs, as improved mobility assists in her wound care. Daily skilled services are required to establish a maintenance program and/or to prevent deterioration of the enrollee's condition. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) 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 IRF admission is medically necessary. The Plan
denied your request. The Plan says the enrollee's needs can be met at a different 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 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 based on the medical records provided the complexity of the enrollee's nursing,
medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary
approach to rehabilitation care. It is not clear the enrollee would be able to fully benefit and/or participate in an
IRF level of care.
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 cardiology services to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve cardiology services. You say that you would like approval for these services to be provided out-of-network. The Plan denied your request. The Plan says there are in-network physicians available for these services.
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 requested provider in this case is not a network provider with the Plan. 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 these items/services. Therefore, we decided that the Plan does not have to pre-approve cardiology services to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services represented by code 99358 provided on January 27, 2021.
You asked the Plan to pay for code 99358. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 99358 is Prolonged evaluation and management service before and/or after direct patient care; first hour. We find that CPT code 99358 is not supported in the medical record. Specifically, code 99358 is used when a prolonged service is provided that is neither face-to face time in the office or outpatient setting, nor additional
unit/floor time in the hospital or nursing facility setting during the same session of evaluation and management and is beyond the usual physician or other qualified health care professional service time. This code may be reported on a different date than the primary service to which it is related. Therefore, we decided that the Plan does not have to pay for the physician services represented by code 99358 provided on January 27, 2021