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

We decided that the Plan does not have to pay for the hereditary cardiovascular genetic testing.

You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says Medicare
denies coverage for all cardiovascular assessment testing, except the basic lipid panel.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed above, are not covered.

The testing at issue in this appeal was requested for screening purposes. Medicare does not cover this testing
for screening purposes. Therefore, we decided that the Plan does not have to pay for the hereditary
cardiovascular genetic testing.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the wound supplies.

You asked the Plan to waive the coinsurance for the wound supplies. You say that you should not be responsible for the wound supplies because you did not place the order and could not use the items. The Plan denied your request. The Plan says you have been asked to pay 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). The enrollee's contract with the Plan clearly says that enrollees must pay 20% coinsurance for durable medical equipment, oxygen/oxygen equipment and related supplies.

The enrollee has been asked to pay $149.24 which is 20% of the allowed amount for the wound supplies. The allowed amount is $746.40. ($746.40 x 20% = $149.24). The wound supplies fall within the "Durable medical equipment (DME) and related supplies" benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the wound supplies.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the coinsurance for the Part B drugs.

You asked the Plan to waive the coinsurance for the Part B drugs. You say that you were not made aware of the change in benefit. The Plan denied your request. The Plan says that you have been asked to pay the correct cost-sharing amount.

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. The Plan did not submit the allowed amounts on the Explanations of Benefits. This means we are unable to determine if the coinsurance amounts you are being asked to pay are correct. Therefore, we decided that the Plan has to waive the coinsurance for the Part B drugs.

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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the $20 copayment charged for a specialist office visit.

You asked the Plan to waive this copayment. You say that this was a follow up visit after surgery and should be no charge. The Plan denied your request. The Plan says this copayment was charged based on the claim submitted by your provider and the Plan contract agreement.

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 copayment for specialist services. 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 $20 copayment charged for a specialist office visit.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve a CPAP machine.

You asked the Plan to pre-approve a CPAP machine. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says that the requested item is not a covered benefit.

The Plan must follow Medicare rules. Medicare rules say that replacement in cases of loss is covered.

We looked at the file and Medicare rules. Review of the file shows that the plan states that a new PAP (positive airway pressure) machine may be supported to replace your current one if it is not working. The supplier must also have checked the device in person and found that it cannot be repaired. This cannot be completed due to the fact that you lost the CPAP machine that you previously had.

The file shows that the enrollee received that previous CPAP device. This means the life of a durable medical equipment item has passed the five-year lifetime requirement. If the enrollee lost the device there would be no device for the medical equipment supplier to physically inspect and determine is unrepairable. Based on this information, we decided that Medicare rules for coverage of a CPAP machine have been met. Therefore, we decided that the Plan has to pre-approve a CPAP machine.

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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the FoundationOne Liquid testing services.

You asked the Plan to pay for the testing services. You say that the test results were needed to determine the
course of treatment for this enrollee. The Plan denied your request. The Plan says the results will not change
the medical management.

The Plan must follow Medicare rules. Medicare rules say that next generation sequencing is only covered under
certain medical indications.

We looked at the file and Medicare rules. The records provided do not indicate the enrollee was seeking further
cancer treatment. Based on this information, we decided that Medicare rules for coverage of the testing services
have not been met. Therefore, we decided that the Plan does not have to pay for the FoundationOne Liquid
testing services.
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 admission to an IRF is medically
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.

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
enrollee does not meet criteria for IRF admission. Our physician reviewer found based on the documentation
provided, the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is
not shown to be able to tolerate fifteen hours per week of rehabilitative services with regular physician
evaluation. The enrollee's care needs can be met at 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 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide additional payment for the hearing aids (V5261).

You asked the Plan to provide additional payment for the hearing aids. You say that the hearing aids should be covered. The Plan denied your request. The Plan says the $500 allowance was already applied to the hearing aids and therefore no additional payment is required.

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 up to a $500 allowance. If the hearing aids cost more than $500 in total, you will be responsible for the difference.

We looked at the file and the Plan's rules. The Plan provided documentation showing that a $500 allowance was applied to the cost of your hearing aids. Based on this information, we decided that the Plan does not have to provide additional payment for the hearing aids (V5261).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services.

You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says you must use network providers to get your medical care and services. The only exceptions are emergencies, urgently needed services when the Plan's network is not available (generally, when you are out of the area), out-of-area dialysis services, and cases in which we authorize the use of out-of-network providers.

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 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 physician's services.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Keytruda with Pemetrexed.

You asked the Plan to pre-approve Keytruda with Pemetrexed. You say that the requested Keytruda with Pemetrexed is medically necessary. The Plan denied your request. The Plan says that the requested Keytruda with Pemetrexed 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 with Pemetrexed. Our reviewer says that the requested Keytruda with Pemetrexed is medically necessary. Our physician reviewer found the enrollee is diagnosed with stage IV non-small cell lung cancer (NSCLC). The requested Keytruda with Pemetrexed is not FDA-approved for the enrollee's diagnosis. Keytruda is only FDA-approved as a single agent after progression. However, the use of Keytruda with Pemetrexed is supported by NCCN Guidelines Version 4.2021 Non-Small Cell Lung Cancer. The documentation supports that the requested Keytruda with Pemetrexed 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 Keytruda with Pemetrexed have been met. Therefore, we decided that the Plan has to pre-approve Keytruda with Pemetrexed.

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 pre-approve a right total shoulder joint replacement.

You asked the Plan to pre-approve a right total shoulder joint replacement. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have 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 right total shoulder joint replacement. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the request for right total shoulder joint replacement is not medically reasonable or 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 right total shoulder joint replacement have not been met. Therefore, we decided that the Plan does not have to pre-approve a right total shoulder joint replacement.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve a Synvisc syringe.

You asked the Plan to pre-approve the Synvisc syringe. You say that the Synvisc syringe is necessary. The Plan denied your request. The Plan says that the available formulary medications have not been attempted. The Plan also says that the there was no documentation provided which shows that the LCD criteria has been met.

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 Synvisc syringe. Our reviewer says that the Synvisc syringe is medically necessary. Our physician reviewer found the documentation supports that you have osteoarthritis of the knees and is symptomatic. The reviewer found that you had significant improvement with the previous Synvisc-One injection, at least 6 months have elapsed, and your symptoms have recurred. The reviewer found that the documentation supports that the Synvisc syringe is safe and effective. Therefore, the reviewer found that the requested Synvisc syringe is medically reasonable and 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 the Synvisc syringe have been met. Therefore, we decided that the Plan has to pre-approve a Synvisc syringe.

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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.

You asked the Plan to pre-approve SNF care. You say that the requested care is necessary. The Plan denied your request. The Plan says rules for 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 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that you have stabilized medically and are ready for discharge from the hospital. You do not require skilled nursing and/or skilled therapy services on a daily basis. Although further rehab services would be appropriate to improve function, as a practical matter, the intermittent skilled services can be provided at a lower level of care than a SNF.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a drug test provided on March 13, 2020.
You asked the Plan to pay for the drug test. The Plan denied your request. The Plan says it is important to know which providers are part of our network because, with limited exceptions, while the enrollee is a member of our plan the enrollee must use network providers to get medical care and services. The only exceptions are emergencies, urgently needed services when the network is not available, out-of-area dialysis services, and cases in which the Plan authorizes use of out-of-network providers.
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 drug test. 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 a drug test provided on March 13, 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 this is medically necessary. The Plan denied your request. The Plan says all the services that would be provided in the LTACH are being provided in the current acute care setting which is already approved.

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 for a septic shoulder. The enrollee is not intubated/ventilated. There is no evidence that the enrollee requires services that are not currently available at the acute care hospital. As LTACHs and acute care hospitals 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 acute care hospital 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 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.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).

You asked the Plan to pre-approve admission to a SNF. You say that the requested admission to a SNF is
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF
admission.

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 admission to a SNF. Our reviewer says
that daily skilled services are not necessary. Our physician reviewer found this enrollee does not require
transfer from an IRF to a SNF. The enrollee does not require skilled nursing services with the specialized skill,
knowledge and judgment of a skilled professional nurse required to safely and effectively provide medically
necessary and reasonable treatment in a SNF. The enrollee's functional level does not require skilled therapy
services with the specialized skill, knowledge and judgment of a qualified therapist required to safely and
effectively provide medically necessary and reasonable treatment in a SNF. Skilled nursing or therapy services
are not required on a daily basis or as a practical matter on an inpatient basis, in a skilled nursing facility
setting. The enrollee can continue to receive appropriate intensive rehabilitation services at the IRF until the
enrollee is ready to safely return to the home or community-based environment.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of admission to a SNF have not been met. Therefore, we decided that the Plan
does not have to pre-approve admission to a skilled nursing facility (SNF).