Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services for the enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs cardiac management, daily physician rounding, blood transfusions, and pain management. The Plan denied your request. The Plan says the enrollee's severity of illness does not meet an LTACH level of designation. 
 
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 physician reviewer found that the enrollee is currently undergoing treatment at an acute care hospital (ACH) for acute cholecystitis, for which he underwent surgery that was complicated by intra-abdominal bleeding. The enrollee was intubated/ventilated peri-operatively, but has since been extubated and is no longer on a ventilator. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. 
 
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 for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Biocept Prostate Profile rendered to the enrollee on
June 10, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that circulating tumor cell (CTC) analysis is denied as not
medically necessary.
The services at issue are a Biocept Prostate Profile, which is a CTC analysis. This testing is denied by Medicare
as not medically necessary. Therefore, we decided that the Plan does not have to pay for the Biocept Prostate
Profile rendered to the enrollee on June 10, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hearing aids from the provider.
You asked the Plan to pre-approve hearing aids from the provider. You say that this is a cheaper option. The Plan denied your request. The Plan says this is not a plan provider.
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 when they are prescribed and provided by a plan provider. We looked the file and the Plan's rules. The provider is not a plan provider for hearing aids. Based on this information, we decided that the Plan's rules for coverage of hearing aids from the provider have not been met. Therefore, we decided that the Plan does not have to pre-approve hearing aids from the provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a hypoglossal nerve stimulator for the treatment of sleep apnea.
You asked the Plan to pre-approve the requested services. You say that the procedure is medically necessary for your life threatening medical condition. The Plan denied your request. The Plan says published literature does not support the services at this time.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pre-approve a hypoglossal nerve stimulator for the treatment of sleep apnea.
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 requested continuation of IRF care is medically necessary. The Plan denied your request. The Plan says the requested continuation of IRF care does not meet criteria.
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 continuation of IRF care does not meet criteria. Our physician reviewer found the enrollee presented to the emergency room after being found unresponsive. Head/neck CTA showed left ICA and left M1 segment occlusions. The enrollee now has post-stroke seizures, neglect, right hemiparesis, and abnormal mobility. The records from 2/6/2020 indicate the enrollee is neurologically stable, though globally aphasic. The enrollee remains moderate/maximum assist for activities of daily living and transfers as of this date, similar to 1/27/2020 assessments. Records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a lower level of care. Ongoing pain medication and other medication management, skin care, and daily therapy can be provided at a lower level of care. In this case, the enrollee is mostly moderate to maximum assist for functional transfers and activities of daily living and a less intensive, longer duration of therapy may be more appropriate. It is not clear the enrollee would be able to fully benefit and/or participate in an IRF level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on October 4, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
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 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 for the medical services provided to the enrollee by an out-of-network provider on October 4, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of Keytruda. 
 You asked the Plan to pre-approve Keytruda. You say that the enrollee needs to continue with Keytruda. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because Keytruda has not been shown to be appropriate or safe for the enrollee's condition. 
 
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 enrollee does not meet the Medicare criteria for use of Keytruda. Our physician reviewer found the enrollee has had progression of cancer while on treatment with Keytruda based on Computed Tomography (CT) imaging reports. The enrollee's cancer is not microsatellite instability high or mismatch repair deficient. Keytruda is not Food and Drug Administration (FDA) approve for use in this case. Keytruda is also not supported by any Medicare-approved drug compendia for the enrollee's condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have to pre-approve use of Keytruda.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a PET CT scan (78815).
You asked the Plan to pre-approve a PET CT scan (78815). You say that the requested PET CT scan is medically necessary. The Plan denied your request. The Plan says that the requested PET CT scan is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are medically 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 a PET CT scan (78815). Our reviewer says that the requested PET CT scan is medically necessary. Our physician reviewer found the enrollee is with metastatic squamous cell cancer on chemotherapy. Based on the documentation provided and Medicare criteria all other cancers not listed are covered for subsequent treatment strategy. The enrollee meets Medicare criteria in this case and the requested PET CT scan is 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 a PET CT scan (78815) have been met. Therefore, we decided that the Plan has to pre-approve a PET CT scan (78815).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the medical eye exam provided on October
1, 2019.
You asked the Plan to waive the copayment for the medical eye exam. You say that this was a routine eye visit
and should be covered. You say they did a test for a cataract but it did not grow. The Plan denied your request.
The Plan says you have been charged the correct cost sharing 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 a $40
copayment per visit for Medicare-covered exams to diagnose and treat diseases of the eye, including an annual
glaucoma screening for members at high risk.
You have been asked to pay a $40 copayment for the medical eye exam. The medical eye exam falls within the
"Vision care" benefit category. The medical record shows a diagnosis of cataracts which makes the eye exam
medical in nature.
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 medical eye exam provided on October 1, 2019.
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 requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH is not medically necessary.
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 admission to a LTACH is not medically necessary. Our physician reviewer found the enrollee was admitted to acute care on 1/9/20 status post C3-7 posterior decompression and C2-T2 posterior fusion on 12/15/19. The enrollee fell twice while at rehab causing backing out of R C3 screw, displacement of bilateral C4 screws and disconnection of vertical stabilizing rods with C2 screws. Long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not provide clinical services that are materially different than those of short term acute care hospitals. In this case, ongoing care needs include respiratory support with oxygen supplementation, surveillance laboratory studies, pain management, tube feedings, and intensive therapy services. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for office visits (99215, 99204), a wellness visit (G0438), alcohol screening (G0442), depression screening (G0444), smoking cessation counseling (99406, 99406), lab services (G8420), functional status (1170F), medications review (1160F), and pain severity quantified (1125F) provided on January 25, 2019 to February 27, 2019 by out of network provider.
You asked the Plan to pay for office visits, a wellness visit, alcohol screening, depression screening, smoking cessation counseling, lab services, functional status, medications review, and pain severity quantified. You say that if the enrollee had reported the correct insurance information at the time of her visit, the authorization would have been obtained and the correct insurance company billed. The Plan denied your request. The Plan says the doctor is a non-network provider who does not work with the health plan. The member self-referred for services. The primary care provider did not refer the member. The health plan requires utilization of network providers when possible and available and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.
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 has network providers available who can provide 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 Plan does not have to pay for office visits (99215, 99204), a wellness visit
(G0438), alcohol screening (G0442), depression screening (G0444), smoking cessation counseling (99406, 99406), lab services (G8420), functional status (1170F), medications review (1160F), and pain severity quantified (1125F) provided on January 25, 2019 to February 27, 2019 by out of network provider.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia (denosumab) injections.
You asked the Plan to pre-approve Prolia injections. You say that the enrollee needs this medication to treat her osteoporosis. The Plan denied your request. The Plan says the rules require a trial of zoledronic acid before covering Prolia.
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 injetions. Our reviewer says that the requested medication is not reasonable and necessary based on step therapy rules. Our physician reviewer found the enrollee has a diagnosis of Age-related osteoporosis without current pathological fracture. There has not been a trial of zoledronic acid. The documentation does not support that Zoledronic acid would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. 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 injetions have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia (denosumab) injections.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the physician visit provided on August 11, 2019.
You asked the Plan to waive the deductible the physician visit. You say that you believe the doctors and hospital are 'double-dipping.' The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $1,364 deductible that applies towards in-network physician visits.
The physician service you asked the Plan to waive the deductible falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that your $1,364 deductible applies to physician visits. The allowed amount for the physician visit is $182.02. Therefore, $182.02 was applied to your $1,364 deductible.
This cost sharing is a contractual obligation that had not been met at the time the physician services was received on August 11, 2019. Therefore, we decided that the Plan does not have to waive the deductible for the physician visit provided on August 11, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the limited oral evaluation (D0140) and the incomplete root canal (D3332) provided on July 31, 2019.
You asked the Plan to reimburse you for the dental services. You say that The Plan denied your request. The Plan says the limited oral evaluation is not a covered service. The Plan also says that prior authorization was not obtained for the incomplete root canal.
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 limited oral evaluation is not among those covered under this benefit. Additionally, authorization was not obtained before you received the incomplete root canal. Therefore, we decided that the Plan does not have to reimburse you for the limited oral evaluation (D0140) and the incomplete root canal (D3332) provided on July 31, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from August 31, 2019 to September 23, 2019.
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee's condition no longer required daily skilled services at an inpatient skilled nursing facility level of care.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the skilled nursing services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 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 skilled nursing services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided from August 31, 2019 to September 23, 2019.
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 the enrollee can receive the care required at the current facility they are in. Therefore, 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 is currently undergoing treatment at an acute care hospital (ACH) for a basilar artery stroke. The enrollee was intubated/ventilated upon presentation and subsequently received a tracheotomy. The enrollee's long-term prognosis and treatment goals are unclear. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care (LTC) 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 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.