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

 
We decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2311, 
E2377, E2313, A9900, K0108). 
 
You asked the Plan to pre-approve the accessories. You say that this is medically necessary. The Plan denied 
your request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.  
 
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 accessories. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found K0108 push handles and K0108 bag and memory seat exceed your medical needs and do not 
serve a primary medical purpose therefore they are not medically necessary. The requested A9900 prep and 
assemble is included in the approved wheelchair therefore this request is not medically necessary. The E2377 
Expandable Controller and E2313 Expandable Controller Harness are not medically necessary per Local 
Coverage Article: Wheelchair Options/Accessories - Policy Article (A52504). The documentation does not 
reveal that you require other types of proportional input devices (e.g., mini-proportional or compact joysticks, 
touchpads, chin control, head control, etc.) or non-proportional input devices (e.g., sip and puff, head array, 
etc.) You do not need to operate 3 or more powered seating actuators through the drive control, a  separate 
display (i.e., for alternate control devices),other electronic devices (e.g., control of an augmentative speech 
device or computer through the chair's drive control), or an attendant control. Your strength and functional 
ability are sufficient to allow you to control any power wheelchair options through their own individual 
switches. 
 
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 accessories have not been met. Therefore, we decided that the Plan does not 
have to pre-approve additional power wheelchair accessories (E2311, E2377, E2313, A9900, K0108).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that a LTACH admission is medically 
necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for 
coverage of a LTACH admission. 
 
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 that the patient was admitted to the current acute care hospital with hypoxic 
respiratory failure due to pneumonia. She was treated with oxygen, fluids, antibiotics, steroids, and Lasix. She 
has interstitial lung disease and required Airvo, but oxygen requirements are lowering based on recent notes 
and stable vitals. The patient appears to be improving sufficiently to need only short-term additional acute care 
services which can safely be received at the current facility. The patient does not require services at the 
LTACH that are already available at the current facility. There are no services at the LTACH that the patient 
requires that are not already available and covered at the current facility. Transfer may be considered when 
treatment has been completed. Therefore, this request for LTACH services will be considered not medically 
necessary 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on September 23, 2020. 
 
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent or 
emergent, nor were they approved in advance. 
 
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 did not pre-approve the 
laboratory services. 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 laboratory services provided on September 23, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the breast ultrasound (CPT Code 76641) provided on February 7, 2020.
You asked the Plan to waive the copayment for the ultrasound. You say that you did not receive an ultrasound for this date of service and you only received a mammogram. The Plan denied your request. The Plan says the claim was processed accordingly with your 2020 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received the breast ultrasound (CPT Code 76641) on February 7, 2020. You were asked to pay a $155 copayment for the ultrasound. Your 2020 EOC states enrollees must pay a $155 copayment for each Medicare-covered radiological diagnostic service, not including X-rays, performed in a physician's office or at a freestanding facility (such as a radiology center or medical clinic). 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 breast ultrasound (CPT Code 76641) provided on February 7, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary. 
 
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 does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for a 
subdural hematoma and frequent falls. Medical conditions are stable. There are no medical needs requiring 
inpatient admission. There are no complex nursing or rehabilitation needs. You do not require treatment by 
multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation 
therapy program. While the medical record documents a need for physical and occupational therapy, it does not 
document a need for an intensive rehabilitation program. There is not a reasonable expectation that you will be 
able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plandoes not haveto pay foroutpatient clinic services provided to the enrollee on August 28, 2020.You asked the Planto pay forthe services. You say that the authorization requirement should be waived.The Plandenied your request. The Plansaysthere was no 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 requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plandoes not haveto pay foroutpatient clinic services provided to the enrollee on August 28, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for extracapsular cataract removal provided
on August 31, 2020.
You asked the Plan to waive the coinsurance for extracapsular cataract removal. You say that you disagree with
the charges because you were told that you would only owe a $40 copayment. The Plan denied your request.
The Plan says the claims were processed correctly and you are being charged the correct amount.
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 outpatient surgery, including services provided at hospital outpatient facilities and ambulatory
surgical centers.
You received extracapsular cataract removal on August 31, 2020, at an outpatient hospital facility. Therefore,
you are responsible to pay your share of the cost-sharing charges. The allowed amount is $1,036.55 and 20% of
that is $207.31.
You have been asked to pay the total coinsurance amount of $207.31 for extracapsular cataract removal.
Extracapsular cataract removal 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 for extracapsular cataract removal provided on August 31, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the 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 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 does not require services at the LTACH that are not available at the acute 
care hospital where he is currently receiving care. There are no services available at the LTACH that the 
enrollee requires that are not available at the health care setting being offered by the health plan. The requested 
LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of 
the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continuation of inpatient mental health care provided to 
the enrollee from February 9, 2021, forward. 
 
You asked the Plan to pre-approve inpatient mental health care. You say that the stay is medically necessary. 
The Plan denied your request. The Plan says the stay is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient mental health care. Our 
physician reviewer found it did not appear medically necessary and reasonable to have psychiatric care 
provided at the acute inpatient level of care rather than a lower level of care beyond the dates in question as the 
enrollee did not have dangerousness to self or others but was compliant with their treatment. The health plan?s 
denial of continued inpatient psychiatric services is appropriate. This enrollee did not appear to require 
inpatient mental health treatment beyond the date in question as she was not a danger to themselves or others 
and did not have any auditory or visual hallucinations while being cooperative with treatment. It did not appear 
that active treatment was taking place beyond the date in question. It did not appear that the services were 
reasonably expected to improve the patient?s condition or for the purpose of diagnosis beyond the date in 
question. Our physician reviewer was unable to find an individualized treatment plan however the entire chart 
is not present. It did appear that the records were supervised and evaluated by a physician. Based upon review 
the records provided for the admission of this enrollee does not meet the criteria for continued acute inpatient 
mental health treatment for the dates in question of February 8, 2021, forward as this enrollee was not shown to 
be a danger to themselves or others. The enrollee was not showing any auditory or visual hallucinations and 
was cooperative/compliant with treatment while not showing any threats the safety. 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient mental health care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve continuation of inpatient mental health care provided to the enrollee from 
February 9, 2021, forward.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Nivolumab and Ipilimumab. 
 
You asked the Plan to pre-approve the drug regimen. The Plan denied your request. The Plan says that the drug 
combination in advanced hepatobiliary cancer warrants further investigation. 
 
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 drug regimen. Our physician 
reviewer found that the enrollee has metastatic gallbladder carcinoma. There are no compendia support for the 
requested drug regimen. However, JAMA Oncology 7/30/2020 6(9)1405-1409 showed a positive benefit in 
patients with advanced biliary tract cancers. The use is not listed as not indicated, not supported or not 
recommended in any of the compendia. The documentation supports that the requested drug is safe and 
effective, and otherwise reasonable and necessary for this enrollee 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the drug regimen have been met. Therefore, we decided that the Plan has to pre-
approve Nivolumab and Ipilimumab.  
 
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean Interim partial denture (D5820) provided September 17, 2020.You asked the Plan to pre-approvethe Interim partial denture. You say that the service was medically necessary to repair a broken tooth.The Plan denied your request. The Plan says the service performed is not covered under your dental benefit.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-approvean Interim partial denture (D5820) provided September 17, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea Superion interspinous and/or interlaminar device (22869, 22870).You asked the Plan to pre-approvea Superion interspinous and/or interlaminar 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 Superion interspinous and/or interlaminar device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the spacer is experimental. Moreresearch is needed to show safety and efficacy. There is no spinal instability. The hardware is not needed.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 Superion interspinous and/or interlaminar device have not been met.Therefore, we decided that the Plan does not have to pre-approvea Superion interspinous and/or interlaminar device (22869, 22870).
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay forlong term acute care hospital (LTACH) care provided from June 4, 2020, to July 29, 2020.You asked the Plan to pay forLTACH care. You say that this should be paid at the billed DRG.The Plan denied your request. The Plan says that the sepsis coding and DRG billed (870) is not supported.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG. DRG 870 is defined as septicemia or severe sepsis with MV > 96 hours. In this case, you billed the services provided June 4, 2020, to July 29, 2020 with DRG 870. 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 LTACH care. Our reviewer says that the billed DRG is supported. Our physician reviewer found the enrollee was transferred to LTACH with respiratory failure, sepsis, and drug overdose. The enrollee was febrile. A septic work-up was ordered. The enrollee was found to have acute respiratory failure, severe sepsis with a urinary tract infection, aspiration pneumonia, acute encephalopathy, and laryngeal edema. The documentation supports the billed DRG and sepsis diagnosis.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of LTACH care have been met.Therefore, we decided that the Plan has to pay forlong term acute care hospital (LTACH) care provided from June 4,2020, to July 29, 2020.If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Zilretta. 
 
You asked the Plan to pre-approve these services. You say that the medication has always helped. The Plan 
denied your request. The Plan says the services are not medically necessary. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the records show that you have pain 
related to osteoarthritis of both knees. You had prior injections of Zilretta in June of 2019, February of 2020, 
and October of 2020. Repeat Zilretta injections are not recommended and are not approved by the FDA. The 
services are therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Zilretta.