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

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the 
enrollee. 
 
You asked the Plan to pre-approve the admission. You say that the enrollee has been struggling to speak and 
move. The Plan denied your request. The Plan says the guidelines for coverage of SNF care have not been met. 
 
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 pre-approve the admission. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled 
nursing or therapy services on a daily basis. The 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 the admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.

You asked the Plan to pre-approve the LTACH services. You say that the enrollee will require another 4-6 weeks of acute care. The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient acute care, and does not require transfer.

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 appears to be more stable and improving with current treatment, but requires additional short term acute care until oxygen requirements reduce further which can be safely completed at the current facility. The enrollee does not require LTACH services that are not already available at the current facility. There are no services at the LTACH that the enrollee requires that are not already available and covered at the current facility. Therefore, this request for LTACH services will be considered not medically necessary at this time. Transfer may be considered soon when treatment has completed and when appropriate for a lower 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 the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the interpretation of a chest x-ray provided on August 24, 
2020. 
 
You asked the Plan to pay for the chest x-ray interpretation. You say that this is not a duplicate because more 
than one scan was done on this date. The Plan denied your request. The Plan says this was correctly denied as 
duplicate. There is no evidence that two x-rays were read on this date. 
 
The Plan must follow Medicare rules. Medicare rules say that exact duplicate claims should be denied. 
 
In this case, two imaging reports were submitted, but these were identical to one another. There was no 
evidence submitted to show that a second interpretation on a second image was performed. Therefore, we 
decided that the Plan does not have to pay for the interpretation of a chest x-ray provided on August 24, 2020.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the eye exam provided on January 25, 2019. 
 
You asked the Plan to pay for the eye exam. You say that you were told to go to this provider and feel this 
should be covered. The Plan denied your request. The Plan says that you were not eligible for an eye exam 
until February 1, 2019. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Per Medicare enrollment history, you have had no breaks in coverage with this 
plan. In addition, no evidence was presented to show when the last routine eye exam was provided. Since this 
benefit is covered once per calendar year, and there is no evidence it was already provided in the 2019 calendar 
year, we find that the denial is not substantiated. Therefore, we decided that the Plan has to pay for the eye 
exam provided on January 25, 2019.  
 
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 pay for the detailed and extensive oral evaluation (D0160), the cone 
beam CT capture and interpretation (D0364), the pulp vitality test (D0460), and the periapical x-ray (D0220) 
provided on September 3, 2020. 
 
You asked the Plan to pay for the dental services. You say that the exam and x-rays that you received were for 
a second opinion. You say that you were advised the exam and x-rays would be covered at 60% but that the 
root canal would not be covered at all. You also say that the claim may have been denied due to the member 
number and member ID not matching. The Plan denied your request. The Plan says the detailed and extensive 
oral evaluation, cone beam CT, and pulp vitality test are not listed as covered services. The Plan says 1 
periapical x-ray is covered per calendar year. The Plan also says that the frequency limit for this service has 
been exceeded. 
 
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 detailed and extensive oral 
evaluation, cone beam CT, and pulp vitality test are not among those covered under this benefit. Additionally, 
the frequency limit of 1 periapical x-ray per calendar year has been exceeded. The record shows that the Plan 
paid for this service that you received on August 25, 2020. Therefore, we decided that the Plan does not have to 
pay for the detailed and extensive oral evaluation (D0160), the cone beam CT capture and interpretation 
(D0364), the pulp vitality test (D0460), and the periapical x-ray (D0220) provided on September 3, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on August 11, 2020.

You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.

The rules say for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. When conducting a review of a covered DME item, ordered by a physician, the contractor shall ensure that the physician saw the beneficiary and conducted a face-to-face assessment. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the durable medical equipment have not been met. Specifically, medical records do not support a prior face-to-face examination with the ordering physician within 6 months of ordering the DME or an appropriate use of telehealth. The submitted consultation notes do not support that a physical examination was performed. The information submitted does not confirm that Medicare coverage criteria have been met. Therefore, we decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on August 11, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve OPDIVO (J9299) and YERVOY (J9228).

You asked the Plan to pre-approve OPDIVO and YERVOY. You say that this is medically necessary. The Plan
denied your request. The Plan says the enrollee tried a similar drug and didn't have a positive response.

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 OPDIVO and YERVOY. Our reviewer
says that the criteria for coverage of OPDIVO and YERVOY have not been met. Our physician reviewer found
this patient has progression of disease less than six months after the completion of immunotherapy for small
cell lung cancer. A different immunotherapy is not indicated after progression shortly after completion. The
combination of nivolumab and ipilimumab is for first line therapy. The service is 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 OPDIVO and YERVOY have not been met. Therefore, we decided that the Plan
does not have to pre-approve OPDIVO (J9299) and YERVOY (J9228).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the amalgam services identified with code D2150 received on September 3, 2020.
You asked the Plan to pay for the amalgam services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services received are not a covered 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 pay for the amalgam services identified with code D2150 received on September 3, 2020.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Gamunex-C injections.

You asked the Plan to pre-approve the Gamunex-C injections. You say that the enrollee's Plan is not billed for, nor reimburses her for her pump.The Plan denied your request. The Plan says that this drug is administered using an infusion pump at home, but the infusion pump is not paid for by Medicare.

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 Gamunex-C injections. Our reviewer says that Gamunex-C is medically reasonable and necessary for the enrollee. Our physician reviewer found Gamunex-C injection is used to treat primary immunodeficiency (PI). This includes, but is not limited to, congenital agammaglobulinemia, common variable immunodeficiency, X-linked agammaglobulinemia, Wiskott-Aldrich syndrome, and severe combined immunodeficiencies. Gamunex-C is also used to increase platelets in enrollee's with idiopathic thrombocytopenic purpura (ITP). Our reviewer found that in this case, the drug is administered using an infusion pump at home. The review has determined that the documentation supports that the Gamunex-C is medically reasonable and necessary for the enrollee. Our physician reviewer also found that the documentation supports that the Gamunex-C is safe and effective for the 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 Gamunex-C injections have been met.Therefore, we decided that the Plan has to pre-approve Gamunex-C injections.If the Plan does not agree with our decision,they can ask us to open a case again. 

We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve a repeat injection of 32 units of Zilretta to the left knee. 
 
You asked the Plan to pre-approve the repeat injection of Zilretta. The Plan denied your request. The Plan says 
that a limitation of Food and Drug Administration (FDA) approval for Zilretta is that it is not intended for 
repeat administration, as safety and efficacy have not been demonstrated. 
 
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 repeat injection of Zilretta. Our 
reviewer says that the repeat injection of Zilretta is medically reasonable and necessary. Our physician 
reviewer found Zilretta (Triamcinolone Acetonide extended-release injectable suspension) is indicated as an 
intra-articular injection for the management of osteoarthritis pain of the knee. Our reviewer found that based on 
the Label, it does not preclude use of the drug more than one time. Our physician reviewer also found that the 
documentation supports that Zilretta is medically reasonable and necessary for the enrollee, and is safe and 
effective for the 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 repeat injection of Zilretta have been met. Therefore, we decided that the 
Plan has to pre-approve a repeat injection of 32 units of Zilretta to the left knee.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: 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 type of service at a rehab facility would be 
advantageous for your recovery. The Plan denied your request. The Plan says the records do not support the 
ability to tolerate an intensive rehab therapy program at least 3 hours a day. 
 
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 patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was 
admitted for left lumbar microdiscectomy. Medical conditions are stable. There are no medical needs requiring 
inpatient admission. There are no complex nursing or rehabilitation needs. 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 this patient 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) stay provided from March 
10, 2020, to March 19, 2020. 
 
You asked the Plan to pay for the SNF stay. You say that the enrollee needed SNF care. The Plan denied your 
request. The Plan says SNF care was not medically necessary. 
 
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 SNF stay. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found although there were identifiable skilled 
therapy service needs there were no identifiable skilled nursing service needs. In addition, the beneficiary did 
not require skilled nursing or therapy services on a daily basis and did 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 the SNF stay have not been met. Therefore, we decided that the Plan does not 
have to pay for the skilled nursing facility (SNF) stay provided from March 10, 2020, to March 19, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the injections (J2704, J2405, J3010, J1885) provided on January 13, 2020 by an out of network (OON) provider.
You asked the Plan to pay for OON injections. You say that these services were medically necessary. The Plan denied your request. The Plan says these 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 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 the injections (J2704, J2405, J3010, J1885) provided on January 13, 2020 by an out of network (OON) provider.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pre-approve a colonoscopy. 
 
You asked the Plan to pre-approve the colonoscopy. You say that this is medically necessary. The Plan denied 
your request. The Plan says that this test may be reasonable and necessary based on the result of a previous 
exam. 
 
The Plan must follow Medicare rules. Medicare rules say that services are covered if 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 the colonoscopy. Our reviewer says that 
the requested colonoscopy is considered medically reasonable and necessary in this case. Our physician 
reviewer found you have blood in your stool. You have a known history of multiple colonic adenomas. A 
repeat colonoscopy is medically necessary at this time with optimal preparation to ensure complete clearing of 
the colon of any residual polyp material, and to effect hemostasis if a colonic source of blood loss is 
determined. 
 
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 colonoscopy have been met. Therefore, we decided that the Plan has to pre-
approve a colonoscopy.  
 
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an outpatient surgery provided by a participating provider on August 18, 2020.You asked the Plan to waive the copayment foran outpatient surgery. You say that you did the injection to prevent a surgery. You say that you do not agree with this copayment. The Plan denied your request. The Plan says the correct copayment has been applied.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 $250 copayment for outpatient hospitalservices. You have been asked to pay a $250 copayment for an outpatient surgery. The injection that you received is considered an outpatient surgery; therefore, the correct copayment has been applied. An outpatient surgery falls within the outpatient hospital services 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 copayment for an outpatient surgery provided by a participating provider on August 18, 2020.