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

We decided that the Plan does not have to pre-approve a CardioMEMS HF system.
You asked the Plan to pre-approve a CardioMEMS HF system. You say that the requested CardioMEMS HF
system is medically necessary. The Plan denied your request. The Plan says the requested CardioMEMS HF
system is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve a CardioMEMS HF system. Our
reviewer says that the requested CardioMEMS HF system is not medically necessary. Our physician reviewer
found the enrollee is with a history of diabetes, hyperlipidemia, hypertension, stroke, carotid stenosis, ischemic
cardiomyopathy and NYSHA Class III congestive heart failure with reduced LV ejection fraction (LVEF 30-
35%) requiring hospitalization.
In this circumstance therapy change based on data obtained from a CardioMEMs device has been demonstrated
in only one trial to help reduce hospital readmission compared to standard medical therapy. Moreover,
concerns have been raised about potential bias in this trial calling into question the results. Therefore, the
efficacy of the CardioMEMS device is uncertain at this time according to leading authorities and not
recommended in current guidelines for the treatment of heart failure. Medicare coverage criteria are not met
since the device should still be considered experimental or investigational.
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 CardioMEMS HF system have not been met. Therefore, we decided that the
Plan does not have to pre-approve a CardioMEMS HF system.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider on December 20, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says there is no network deficiency 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 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 nota network provider with the Plan. The Plan has network providers available who can provide 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 forthe medical services provided to the enrollee by an out-of-network provider on December 20, 2019
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the duplex scans provided on January 16, 2020.
You asked the Plan to waive the copayment for the duplex scans. You say that this was a follow-up appointment. You say that this should have been paid. The Plan denied your request. The Plan says the copayments applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay an $85 copayment for each Medicare-covered radiological diagnostic service, not including x-rays, performed in an in-network physician's office or at a free-standing facility. You have been asked to pay an $85 copayment for each duplex scan. The total amount you owe is $170 ($85/scan x 2 scans = $170). The duplex scans fall within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" benefit category. There is no provision in the contract which indicates a copayment would be waived if performed as a follow-up. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the duplex scans provided on January 16, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe retinal repair provided on January 9, 2020.You asked the Plan to waive the coinsurance forthe retinal repair. You say that previous out-of-network surgeries were covered in full. You say that this wasn't covered in error.The Plan denied your request. The Plan says the coinsurance applied correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for each Medicare-covered visit to an out-of-network outpatient facility or ambulatory surgical center. You have been asked to pay $268.40, which is 20% of the allowed amount for the retinal repair. The allowed amount is $1,341.99 (20% x $1,341.99 = $268.40). The retinal repair falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance forthe retinal repair provided on January 9, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CardioMEMs implanted device (33289).
You asked the Plan to pre-approve a CardioMEMs implanted device. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has 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 a CardioMEMs implanted device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found in this circumstance therapy change based on data obtained from a CardioMEMs device has been demonstrated in only one trial to help reduce hospital readmission compared to standard medical therapy. Moreover, concerns have been raised about potential bias in this trial calling into question the results. Therefore, the efficacy of the CardioMEMS device is uncertain at this time according to leading authorities and not recommended in current guidelines for the treatment of heart failure. Medicare coverage criteria are not met since the device should still be considered experimental or investigational. 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 CardioMEMs implanted device have not been met. Therefore, we decided that the Plan does not have to pre-approve a CardioMEMs implanted device (33289).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe observation stay provided from November 13, 2019 through November 14, 2019.You asked the Plan to waive the copayment forthe observation stay. You say that this stay was a result of a follow-up appointment. You say that this wasa continuation of the surgery and should be covered.The Plan denied your request. The Plan says the copayment applied correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $500 copayment per day for in-network observation services.You have been asked to pay a $500 copayment for the observation stay. The observation stay falls within the "Outpatient hospital services" benefit category. The records show that this was a separate admission. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment forthe observation stay provided from November 13, 2019 through November 14, 2019.
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 above. 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 do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your medical status does not currently require intensive physician and nursing oversight only in an IRF. You may benefit from multiple therapies such as physical and occupational therapy but the documentation does not support that you require therapy on an 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dexamethasone sodium phosphate and fosnetupitant/palonosetron.
You asked the Plan to pre-approve dexamethasone sodium phosphate and fosnetupitant/palonosetron. The Plan denied your request. The Plan says that this is not being used 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 dexamethasone sodium phosphate and fosnetupitant/palonosetron. Our reviewer says that dexamethasone sodium phosphate and fosnetupitant/palonosetron are not medically reasonable and necessary in this case. The NCCN compendium recommends the use of the two drugs before parenteral anticancer therapy with high emetic risk with or without Olanzapine (preferred with Olanzapine) moderate emetic risk, for select patients with additional risk factors or previous treatment failure with a corticosteroid + serotonin receptor antagonist alone. The submitted documents do not indicate the enrollee has had treatment failure with any prior anti-emetics. Our physician reviewer found that your condition does not meet criteria for coverage of dexamethasone sodium phosphate and fosnetupitant/palonosetron. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of dexamethasone sodium phosphate and fosnetupitant/palonosetron have not been met. Therefore, we decided that the Plan does not have to pre-approve dexamethasone sodium phosphate and fosnetupitant/palonosetron.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve one home health care nursing visit.
You asked the Plan to pre-approve one home health care nursing visit. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 one home health care nursing visit. Our reviewer says that the documentation does not support that the requested home health service is medically reasonable or necessary. Our physician reviewer found the enrollee was independent with mobility and activities of daily living. The enrollee had no pain. The enrollee has received education of the enrollee's condition and medications. The documentation does not support that skilled nursing services are required to effectively provide treatment, care, and/or services in order to improve the enrollee's condition, or to establish/perform a maintenance program to maintain the enrollee's condition and/or prevent deterioration.
There are no ongoing skilled nursing needs. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of one home health care nursing visit have not been met. Therefore, we decided that the Plan does not have to pre-approve one home health care nursing visit.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveTepezza.You asked the Plan to pre-approvethe Tepezza. You say that you would like reconsideration because this drug is medically necessary.The Plan denied your request. The Plan says this drug is not medically indicated for your condition.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 the Tepezza. Our reviewer says that review of the compendia and studies notesoptic neuropthy was an exclusion criterion for the study. Our physician reviewer found the benefit of Tepezza cannot be extrapolated for you and medical necessity is not supported.We looked at this physician's review, the file, and Medicare rules. Basedon this information, we decided that Medicare rules for coverage of the Tepezza have not been met.Therefore, we decided that the Plan does not have to pre-approveTepezza.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay fora hearing aid dispensing fee (V5160) provided on July 10, 2019.You asked the Plan to pay fora hearing aid dispensing fee. You say that you were not informed that you would be charged.The Plan denied your request. The Plan says your hearing aid benefit has been exhausted.Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only up to a $500 allowance for hearing aids every 3 years. We looked at the file and the Plan's rules. The record shows that the $500 allowance was used in May 2019. This means that your hearing aid benefit has been exhausted. Based on this information, we decided that the Plan's rules for coverage of a hearing aid dispensing fee have not been met.Therefore, we decided that the Plan does not have to pay fora hearing aid dispensing fee (V5160) provided on July 10, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveadmission to an inpatient rehabilitation facility (IRF).You asked the Planto pre-approveIRF care. You say that this is medically necessary.The Plandenied your request. The Plansaysthe services can be safely received in other settings, such as skilled nursing facility, home with home health and home physical therapy, or home with outpatient therapy.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.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 do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You have renal failure and hemodialysis has been initiated. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The recommendation of the physical therapist for discharge to skilled nursing facility when stable for discharge. There is no documentation that you are able to participate in an intensive rehabilitation therapy process.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 Plandoes not haveto pre-approveadmission to an inpatient rehabilitation facility (IRF).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genetic testing for the enrollee.
You asked the Plan to pre-approve the testing. You say that this is medically necessary to rule out leukemia.
The Plan denied your request. The Plan says the records do not show that the required other tests have been
done.
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 testing. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found the case file does not contain documentation that BCR-ABL was previously completed and was
negative.
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 pre-approve genetic testing for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out of
network (OON) provider.
You asked the Plan to pre-approve office visit. You say that you are familiar with this doctor and feel more
comfortable being treated by them. The Plan denied your request. The Plan says the denial of authorization for
this service is correct, because this provider is out-of-network with the Plan and you can be treated by an in-network
provider.
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 medical services 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-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the enrollee resides alone in an assisted living facility using an EEW but is independent for all other activities of daily living. You say that IRF careis medically reasonable and necessary.The Plan denied your request. The Plan says the guidelines for coverage have not been met. The Plan says that the services needed 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 above.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 andrehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's medical status does not currently require intensive physician and nursing oversight only in an IRF. The enrolleemay benefit from multiple therapies such as physical and occupational therapy but the documentation does not support that she requires this therapy on an 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-approveacute inpatient rehabilitation facility (IRF) admission and services.