Persius/hicric huggingface dataset:
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 for the enrollee.
You asked the Plan to pre-approve IRF care. You say that the member will benefit with the admission to acute rehab. The Plan denied your request. The Plan says that the enrollee's ongoing skilled therapy and nursing needs can be provided at a lower level of care.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for unstable angina and had coronary artery bypass grafting. The enrollee's medical conditions are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The patient does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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 for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveKeytruda.You asked the Plan to pre-approveKeytruda. You say that this requested drug treatment is medically necessary for the enrollee's condition.The Plandenied your request. The Plan says Keytruda is not medically necessary and reasonable 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 requested drug is not medically reasonable and necessary for the enrollee's condition. Our physician reviewer found the enrollee is a 67-year-old woman diagnosed with stage IV pancreatic cancer. In this case, Keytruda is notFDA-approved for the enrollee's condition without progression on prior therapy. Furthermore, the use of Keytruda for the enrollee's medical condition is not supported by one of the major drug compendia or by clinical research that appears in a CMS-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-approveKeytruda
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a stationary gaseous oxygen system (E0424).
You asked the Plan to pre-approve stationary gaseous oxygen system. You say that you are appealing this denial. The Plan denied your request. The Plan says the denial of authorization for this item is correct, because this device is not being requested for a diagnosis of cluster headaches which is the only covered use of this device.
The Plan must follow Medicare rules. Medicare rules say that a stationary gaseous oxygen system (E0424) is only covered for treatment of cluster headaches. We looked at the file and Medicare rules. This device is not being requested for treatment of cluster headaches. Based on this information, we decided that Medicare rules for coverage of stationary gaseous oxygen system have not been met. Therefore, we decided that the Plan does not have to pre-approve a stationary gaseous oxygen system (E0424).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care.
You asked the Plan to pre-approve continued SNF care. You say that the requested continuation of SNF care is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for continued SNF care.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 pre-approve continued SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee is with dementia, traumatic brain injury, seizure disorder and falls. From a nursing perspective, the enrollee received oral medications. The enrollee had stable vital signs. Her lungs were clear. Regarding rehabilitation services, the enrollee received physical therapy, speech therapy and occupational therapy in the SNF. By the dates in question, the enrollee was at a modified independent to stand by assist/contact guard assist level with functional mobility including gait to 150 feet x 2 with a rolling walker. The enrollee required varying assist with activities of daily living. She had ongoing cognitive impairment. There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. This enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 continued SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a personal helper.
You asked the Plan to pre-approve a personal helper. The Plan denied your request. The Plan says you must provide medical records or a statement of medical necessity from your provider.
The Plan contract says You must get prior approval from the Plan and support by your health care provider is required for the personal home helper benefit.
We looked at the file and the Plan's rules. The file shows that you have not provided the Plan with medical records or a statement of medical necessity from your provider. Therefore, we decided that the Plan does not have to pre-approve a personal helper.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM).
You asked the Plan to pre-approve therapeutic CGM. You say that you check your glucose levels 3 times per
week currently but could check them 3 times or more per day with a therapeutic continuous glucose monitor.
The Plan denied your request. The Plan says you do not meet the Medicare criteria for a therapeutic continuous
glucose monitor.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based
on the blood glucose testing results.
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood
glucose testing at least four times per day, use insulin with at least three daily injections, and 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 therapeutic CGM have not been met. Therefore, we decided that
the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approveLipiflow, evacuation of meibomian glands, automated, using heat and intermittent pressure, unilateral (0207T).You asked the Plan to pre-approveLipiflow treatment. You say that since you have had the regular treatments and suffered with this condition for a very long time, you are appealing this decision.The Plan denied your request. The Plan says Lipiflow is unproven and investigational as there is insufficient evidence of the efficacy for the treatment of blepharitis.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The rules also say that experimental and investigational devices are not covered. We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Lipiflow treatment have not been met.Therefore, we decided that the Plan does not have to pre-approveLipiflow, evacuation of meibomian glands, automated, using heat and intermittent pressure, unilateral (0207T).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an extra spare battery for portable oxygen concentrator.

You asked the Plan to pre-approve the spare battery. You say that your current battery does not extend past 2-3 hours and you have often run out of oxygen if out at medical appointments, going to the lab or grocery shopping.

The Plan denied your request. The Plan says a spare battery is considered a convenience item and is not covered.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. 

The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured.Therefore, we decided that the Plan does not have to pre-approve an extra spare battery for portable oxygen concentrator.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Formoterol.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says that 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 medically necessary. Our physician reviewer found the enrollee has chronic obstructive pulmonary disease. The requested drug is prescribed for maintenance purposes. The FDA states that Formoterol inhalation solution is indicated for long-term, twice daily administration in the maintenance treatment of patients with COPD including chronic bronchitis. The Formoterol is reasonable and medically necessary and considered safe and effective for 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 these services have been met. Therefore, we decided that the Plan has to pre-approve Formoterol.
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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for additional units of computed tomography (CT) scans (70496, 70498) provided December 29, 2020.

You asked the Plan to pay for additional units of CT scans. You say that you would like these claims reprocessed and approved for payment. The Plan denied your request. The Plan says the documentation does not support the additional units billed.

The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value for the HCPCS/CPT code will be denied.

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 additional units of CT scans. Our reviewer says that the requested additional imaging services were not medically necessary and reasonable. Our physician reviewer found that per the CMS Medical Unlikely Edits (MUE) table, the MUE value for CPT code 70496 and 70498 is set at 2 per date of service. Review of claims history shows 70496 and 70498 was billed and paid under the claim for 70450 for the same date of service by the same provider. Supporting documentation was reviewed and does not support additional units of CPT code 70496 and 70498 as being performed for date of service 12/29/2020.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of additional units of CT scans have not been met. Based on this information, we decided that Medicare rules for coverage of additional units of CT scans have not been met. Therefore, we decided that the Plan does not have to pay for additional units of computed tomography (CT) scans (70496, 70498) provided December 29, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that the enrollee meets all applicable Medicare criteria. The Plan denied your request. The Plan says based on Medicare guidelines; the enrollee does not meet the requirements for approval.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that based on the documentation provided, the health Plan's denial should be upheld. The enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require, or to be able to tolerate, fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at a lower level of care (ex. skilled nursing facility/subacute rehab).

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 IRF admission and services.
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 the requested Keytruda is medically necessary. The Plan denied your request. The Plan says the requested Keytruda is not medically necessary.
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 Keytruda is not medically necessary. Our physician reviewer found the record indicates that the enrollee was diagnosed with stage IV metastatic occult primary cancer, most likely ovarian serous in origin (MSI stable. TMB=2.1mut/Mb. PDL1<1%). The Medicare approved cancer compendia do not contain supportive citations for the requested agent to be used in this clinical scenario with MSI stable. TMB=2.1mut/Mb. PDL1<1%. No literature from Medicare approved cancer journals was submitted in support of the requested use. The elements of the coverage criteria are not satisfied. The requested service cannot be
recommended. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have to pre-approve Keytruda.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the computed tomography (CT) scan of abdomen and pelvis (74176).

You asked the Plan to pre-approve the CT scan of abdomen and pelvis. You say that this request is medically necessary. The Plan denied your request. The Plan says they were not able to obtain medical records to support this request.

The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Specifically, there were no medical records provided in this case. Without the medical records, we cannot review to see if the services were urgent/emergent or medically necessary. Therefore, we decided that the Plan does not have to pre-approve the computed tomography (CT) scan of abdomen and pelvis (74176).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Go Chair Med power wheelchair.
You asked the Plan to pre-approve a Go Chair Med. You say that the requested item is a medical necessity for you. The Plan denied your request. The Plan says rules for durable medical equipment have not been met.
The Plan must follow Medicare rules. Medicare rules say that MA plans may specify brands and manufacturers as preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred brands and manufacturers. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a Go Chair Med have not been met. Specifically, the case record does not contain documentation to support that the specific requested power wheelchair is medically necessary in this case. Therefore, we decided that the Plan does not have to pre-approve a Go Chair Med power wheelchair.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the chest and CT scan of the abdomen/pelvis.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that CT 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has had a less than seven pound weight loss in one year. The record does not indicate any work up to date. The record indicates that the requested tests were ordered at the spouse's request. The records do not support that the CT scans are reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the chest and CT scan of the abdomen/pelvis.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the tangential biopsy of skin (11103) provided February 14, 2020.

You asked the Plan to pay for the tangential biopsy of skin. You say that you would like this claim reprocessed for medical necessity.The Plan denied your request. The Plan says they do not have enough information to determine if the services were medically necessary.

The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Specifically, there were no medical records provided in this case. Without the medical records, we cannot review to see if the services were urgent/emergent or medically necessary.Therefore, we decided that the Plan does not have to pay for the tangential biopsy of skin (11103) provided February 14, 2020.