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

 We decided that the Plan does not have to pre-approve Prolia.  You asked the Plan to pre-approve Prolia. You say that this drug is medically reasonable and 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 Prolia. Our reviewer says that the requested drug is not medically reasonable and necessary. Our physician reviewer found that the record indicates that the enrollee has age related osteoporosis without osteoporotic fracture. The requested medication is a new start. The provided records indicates that the enrollee has failed oral bisphosphonates. The provided records do not indicate that the enrollee has tried and failed the plan's preferred step one alternative, zoledronic acid. The record does not credibly indicate that the enrollee has a contraindication to, or would have an adverse effect from the plan's preferred step one alternative, zoledronic acid.  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 Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the lab services provided on May 4, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the services provided. You say that the services should not require pre-authorization. The Plan denied your request. The Plan says the services were not urgent or emergent, and authorization was not 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 had network providers available who could have provided the lab services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the lab services provided on May 4, 2021, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve use of pembrolizumab (Keytruda).  You asked the Plan to pre-approve pembrolizumab. You say that the enrollee needs to start Lenvima along with Keytruda. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because this is not being requested for a medically-accepted indication.  The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve pembrolizumab. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested use of pembrolizumab. Our physician reviewer found pembrolizumab is not Food & Drug Administration (FDA) approved for the enrollee's diagnosis. FDA approval is for the treatment of advanced endometrial carcinoma that is not microsatellite instability-high (MSI-H) or mismatch repair deficient (dMMR) in patients who have disease progression following prior systemic therapy and are not candidates for curative surgery or radiation. 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 pembrolizumab have not been met. Therefore, we decided that the Plan does not have to pre-approve use of pembrolizumab (Keytruda).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the pneumatic compression device (E0651) and segmental pneumatic appliance (E0667) to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve the pneumatic compression device and appliance. You say that you are aware that you are not in network but are pursuing a GAP authorization due to the unique needs of the enrollee. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. The Plan has approved coverage of the requested items through an in-network DME 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 the pneumatic compression device (E0651) and segmental pneumatic appliance (E0667) to be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Gabapentin.  You asked the Plan to pre-approve this drug. You say that this medication has provided significant relief. The Plan denied your request. The Plan says that this is not covered under 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 Gabapentin.   Benefits for this drug 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 enrollee fully meets criteria for IRF. The Plan denied your request. The Plan says the denial of authorization for IRF service is correct.  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 the enrollee's nursing, medical, and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the enrollee may require daily skilled nursing and/or skilled therapy, there is no documented need for an intensive rehabilitation therapy program. There is not a reasonable expectation that this 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. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services coded 87486, 87496, 87498, 87502, 87532, 87541, 87581, 87634, 87640, 87798, 87500, and 87641 provided on October 13, 2020.  You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.  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 find that CPT codes 87486, 87496, 87498, 87502, 87532, 87541, 87581, 87634, 87640, 87798, 87500, and 87641 are not supported in the medical record. Specifically, the place of service on the CMS-1500 form line 24B must reflect the location of the patient when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in an office setting, place of service 11; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in a skilled nursing facility, place of service 31. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services coded 87486, 87496, 87498, 87502, 87532, 87541, 87581, 87634, 87640, 87798, 87500, and 87641 provided on October 13, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve LTACH services.  You asked the Plan to pre-approve the LTACH services. You say that a LTACH admission is medically necessary. The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient acute care and is currently unstable for transfer to a LTACH.  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 the enrollee is a 52 year old male with cerebral palsy who was admitted to the current acute care hospital with altered mental status, sepsis, and acute hypoxic respiratory failure related to aspiration pneumonia treated with antibiotics, BiPAP, but later required intubation, trach, and PEG. The course was complicated by copious secretions, hypoglycemia. Recent notes state that his acute encephalopathy has resolved, and he is at his baseline but remains on D10 and tube feeds. The enrollee is improving and is more stable and should only require short-term additional acute care services that can be safely received at the current facility until more appropriate for a lower level of care.  The enrollee does not require services at the LTACH that are not already available at the current acute care facility. There are no services at the LTACH that the enrollee requires that are not already available and covered at the current facility. Therefore, the LTACH services will be considered not medically necessary as transfer would not be advantageous clinically compared to completing care 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 LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an endodontic therapy (D3320).  You asked the Plan to pre-approve the endodontic therapy. You say that the root canal is needed due to pain in your tooth and you are unable to pay for the procedure. The Plan denied your request. The Plan says this service is 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.  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an endodontic therapy (D3320).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve acute inpatient hospital care.  You asked the Plan to pre-approve acute inpatient hospital care. You say that the enrollee is scheduled for surgery. The Plan denied your request. The Plan says the denial of authorization for acute inpatient hospital level of care is correct, because the enrollee is stable and the documentation does not support an expectation that the enrollee will require more than 2 midnights of hospital care.  The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve acute inpatient hospital care. Our reviewer says that the enrollee does not meet criteria for acute inpatient level of care for right reverse total shoulder arthroplasty. Our physician reviewer found the enrollee is stable and the documentation does not support an expectation that the enrollee will require more than 2 midnights of hospital care for an ambulatory procedure on a lower-risk patient.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for laboratory services provided to the enrollee on May 3, 2021. You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says one code must be submitted for this panel.  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 find that the various denied CPT codes are not supported in the medical record. Specifically, the testing at issue in this case should be reported with CPT 81479. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services provided to the enrollee on May 3, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve pneumatic compression devices (E0652, E0667).  You asked the Plan to pre-approve pneumatic compression devices. You say that the requested item is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for pneumatic compression devices have not been met.  The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required.  We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. The item coded E0667 is not separately payable when the base item is not covered. Therefore, we decided that the Plan does not have to pre-approve pneumatic compression devices (E0652, E0667).
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve bioimpedance spectroscopy (BIS), extracellular fluid analysis (93702).  You asked the Plan to pre-approve the BIS services. You say that this service is medically necessary. The Plan denied your request. The Plan says based on the additional information available, the request does not meet the Medicare or health plan coverage criteria  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 BIS services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that in this case, the provided medical records do not support the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. There is insufficient literature to establish the requested test as safe and effective, as defined by Medicare rules, for the enrollee's specific clinical condition. 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 the BIS services have not been met. Therefore, we decided that the Plan does not have to pre-approve bioimpedance spectroscopy (BIS), extracellular fluid analysis (93702).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve power wheelchair accessories.  You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says you do not meet the requirements for coverage.  The Plan must follow Medicare rules. Medicare rules say that wheelchair options and accessories are only covered under certain medical indications.   The file shows that power tilt, elevating leg rests, and an electronic connection were requested for a power wheelchair. 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 requested items. Our physician reviewer says that you have a past medical history of systemic lupus erythematosus, osteoarthritis, fibromyalgia, chronic obstructive pulmonary disease and low back pain who requires a power wheelchair for mobility. The records do not show that you are at high risk for developing a pressure ulcer or are not able to transfer from a wheelchair to bed. You do not utilize intermittent catheterization for bladder management. You do not have a cast, brace or musculoskeletal condition which prevents 90-degree flexion of the knee or has significant edema of the lower extremities. Based on the medical records provided there is no documentation that the coverage criteria for the requested wheelchair items have been met.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve power wheelchair accessories.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.  You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says care could be received in another setting.  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 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 was admitted for surgical repair of a hip fracture after a fall. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that this 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. Therefore, we decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.