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

 We decided that the Plan does not have to pre-approve Keytruda.  

You asked the Plan to pre-approve Keytruda. You say that this drug is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage have not been met.  

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 is not medically necessary for the enrollee's condition. Our physician reviewer found the enrollee is a 78-year-old with respectable ampullary cancer with comorbidities. In this case, Keytruda is not FDA-approved for the enrollee's condition as there has been no prior treatment. In addition, the use of Keytruda is not supported by one of the major drug compendia or by clinical research that appears 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 Keytruda have not been met. Therefore, we decided that the Plan does not have to pre-approve Keytruda.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Ondansetron.  You asked the Plan to pre-approve Ondansetron. You say that the requested drug is medically necessary. The Plan denied your request. The Plan says the requested drug is not covered under the medical benefit.  The Plan must follow Medicare rules. Medicare rules say that Self-administered anti-emetics to reduce the side effects of nausea and vomiting brought on by the primary drug are not included beyond the administration necessary to achieve drug absorption.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Ondansetron have not been met.    Specifically, the file shows that the requested drug is being prescribed for epigastric pain associated with ulcerative colitis. The file also shows that it is not being given within 48 hours of chemotherapy and is not a full replacement for intravenous medications. Therefore, we decided that the Plan does not have to pre-approve Ondansetron.   Benefits for Ondansetron 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: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a power connection for elevating leg rests on a power wheelchair (E2311).  You asked the Plan to pre-approve the power connection. You say that the connection is medically necessary. The Plan denied your request. The Plan says coverage rules have not been met.  The Plan follows Medicare rules. Medicare rules say that a power leg elevation feature involves dedicated motor(s) and related electronics with or without variable speed programmability which allows the leg rest to be raised.  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 power connection. Our reviewer says that the requested electrical connection is not medically necessary. Our physician reviewer found the elevating leg rests include their own switches. The record shows the enrollee is capable of operating these switches. It is not medically necessary to connect this feature to the joystick controller.  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 power connection have not been met. Therefore, we decided that the Plan does not have to pre-approve a power connection for elevating leg rests on a power wheelchair (E2311).
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the Vertiflex procedure.  You asked the Plan to pre-approve Vertiflex. You say that the enrollee is a good candidate for Vertiflex. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because the enrollee does not meet criteria for Vertiflex.  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 Vertiflex. 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 its safety and efficacy.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Vertiflex have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex procedure.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve F2 and F5 gene analysis.  You asked the Plan to pre-approve F2 and F5 gene analysis. 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 a covered benefit.  The Plan must follow Medicare rules. Medicare rules say that genetic testing for thrombophilia for Factor V Leiden variant of F5 gene or variant in F2 gene are non-covered except for enrollees who are pregnant.  We looked at the file and Medicare rules. Review of the file does not support that you are pregnant. Based on this information, we decided that Medicare rules for coverage of F2 and F5 gene analysis have not been met. Therefore, we decided that the Plan does not have to pre-approve F2 and F5 gene analysis.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve insertion of an interspinous spacer device (Vertiflex).  You asked the Plan to pre-approve Vertiflex procedure. You say that this is highly recommended when conservative treatment has failed and as a safer alternative to a laminectomy or spinal fusion. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because the enrollee does not meet the criteria for Vertiflex.  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 Vertiflex procedure. 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 its safety and efficacy.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Vertiflex procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve insertion of an interspinous spacer device (Vertiflex).
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a Vertiflex procedure (22869, 22870).  You asked the Plan to pre-approve a Vertiflex procedure. You say that the requested procedure is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met because the requested procedure is experimental/investigational.  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 a Vertiflex procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the procedure at issue is still considered experimental/investigational as 2 learned societies have not endorsed its use in spinal stenosis.  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 Vertiflex procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex procedure (22869, 22870).
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services (88305, 88312) rendered by an out-of-network (OON) provider on June 30, 2021.  You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization.  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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the 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 laboratory services (88305, 88312) rendered by an out-of-network (OON) provider on June 30, 2021.
Appeal type: Surgery
Decision: Favorable

 We decided that the Plan has to pre-approve the gastric bypass surgery.  You asked the Plan to pre-approve the gastric bypass surgery. You say that this surgery is medically reasonable and necessary for your condition. The Plan denied your request. The Plan says that the criteria for the requested bariatric surgery have not been met.  The Plan must follow Medicare rules. The rules say that Medicare will cover bariatric surgery for enrollees who have:   (1) a body mass index (BMI) of greater than or equal to 35;   (2) at least one co-morbidity related to obesity; and  (3) been unsuccessful with medical treatment for obesity.    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 gastric bypass surgery. Our reviewer says that the requested surgery is medically reasonable and necessary. Our physician reviewer found you are an adult female with BMI that is greater than 35 kg/m2, it is 46.7 kg/m2. You also have several weight related co-morbid conditions including gastroesophageal reflux disease and increased cholesterol. Furthermore, you have also failed medical efforts at weight loss. The patient meets all Medicare criteria for bariatric surgery at this time.  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 gastric bypass surgery have been met. Therefore, we decided that the Plan has to pre-approve the gastric bypass surgery.     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: Favorable

 We decided that the Plan has to pre-approve Eligard (J9217).  You asked the Plan to pre-approve Eligard. You say that this is medically necessary. The Plan denied your request. The Plan says that this is self-administered.  The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The rules also say that synthetic luteinizing hormone-releasing hormone (LHRH) analogs (also called LHRH agonists) available in the United States include leuprolide acetate (Lupron, Eligard, Viadur). These drugs may be administered by injection or placed as small implants under the skin monthly, or every 3, 4, 6, or 12 months, depending on the preparation. The Food and Drug Administration (FDA) approved indications and recognized off-label uses (which meet criteria in Local Coverage Determination L33394) vary by product. Code J9218 (leuprolide acetate, per 1 mg.) describes a usually self-administered form of leuprolide acetate.  The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Though the Plan denied Eligard as self-administered, Eligard, requested with code J9217, is not a form of leuprolide acetate that is usually self-administered. The record does not support that this drug will be self-administered or dispensed in a pharmacy. Therefore, we decided that the Plan has to pre-approve Eligard (J9217).   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: Inpatient Hospital
Decision: Favorable

 We decided that the Plan has to pay for the acute inpatient hospital care provided from July 9, 2021, to July 11, 2021.  You asked the Plan to pay for acute inpatient hospital care. You say that the inpatient care was medically necessary. The Plan denied your request. The Plan says that the inpatient admission was not medically necessary.  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 pay for acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the record shows that at the time of inpatient admission the admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier emergency department and/or observation care) would span two midnights.  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 been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from July 9, 2021, to July 11, 2021.   If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Freestyle Libre 14-day reader device.  You asked the Plan to pre-approve Freestyle Libre 14-day reader device. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested item.  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 or require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of Freestyle Libre 14-day reader device have not been met. Therefore, we decided that the Plan does not have to pre-approve Freestyle Libre 14-day reader device.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a computed tomography scan of the abdomen, pelvis and chest.  You asked the Plan to pre-approve this imaging. You say that this imaging is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met.  The Plan must follow Medicare rules. Medicare rules say that this type of imaging is covered only when medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules. Our reviewer says the medical records show you were seen by your primary care physician and blood work was performed which was unremarkable. You are not anemic. You do not have elevations in liver chemistries. You have a normal serum albumin and protein to suggest normal absorption. Testing for celiac with serology was negative. The differential diagnosis is broad. Medicare coverage criteria for imaging are not met. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this imaging have not been met. Therefore, we decided that the Plan does not have to pre-approve a computed tomography scan of the abdomen, pelvis and chest.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a high speed motor package, flip up foot platform, and power seat elevation system for a power wheelchair.  You asked the Plan to pre-approve a high speed motor package, flip up foot platform, and power seat elevation system. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested items are not a covered benefit.  The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.    The high speed motor package and flip up foot platform at issue in this appeal do not serve a purpose that is primarily medical in nature. These items are available to the general public and would be helpful even to those who are not sick or injured. A power seat elevation feature is non-covered. Therefore, we decided that the Plan does not have to pre-approve a high speed motor package, flip up foot platform, and power seat elevation system for a power wheelchair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a shower chair.  You asked the Plan to pre-approve a shower chair. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says a shower chair is not covered by Medicare or the Plan.  The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature.   While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve facet joint injection services.  You asked the Plan to pre-approve facet joint injection services. You say that this service is medically necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met.  The Plan follows Medicare rules. Medicare rules say that facet joint interventions are considered medically reasonable and necessary when the criteria in the Medicare rules section have been 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 facet joint injection services.    Our reviewer says that the requested services are not medically reasonable and necessary. Our physician reviewer found that the review indicates that the enrollee is a 57-year-old female with a history of low back pain with radiation to both legs. The pain has been present for 20 years and is the result of an auto related injury.  In this case, the enrollee has radiculopathy. The review has determined that the enrollee does not meet the listed coverage criteria for the requested facet joint injection. The review has determined that the requested service is not medically reasonable or necessary.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of facet joint injection services have not been met. Therefore, we decided that the Plan does not have to pre-approve facet joint injection services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve endodontic therapy (D3320), pontic (D6245), retainer crowns (D6740) and occlusal guard (D9944).  You asked the Plan to pre-approve endodontic therapy (D3320), pontic (D6245), retainer crowns (D6740) and occlusal guard (D9944). The Plan denied your request. The Plan says the services are not covered benefits.  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 endodontic therapy (D3320), pontic (D6245), retainer crowns (D6740) and occlusal guard (D9944).
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve transforaminal epidural injections (62323, 64483).  You asked the Plan to pre-approve transforaminal epidural injections. You say that the requested services are a medical necessity for the enrollee. The Plan denied your request. The Plan says medical necessity rules for the requested services have not been met.  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 transforaminal epidural injections. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that it is not considered medically reasonable and necessary to perform transforaminal epidural steroid injections at more than two (2) nerve root levels during the same session.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of transforaminal epidural injections have not been met. Therefore, we decided that the Plan does not have to pre-approve transforaminal epidural injections (62323, 64483).