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

We decided that the Plan has to pre-approve the requested hospital services.
You asked the Plan to pre-approve hospital services. You say that cannot move for several days after this surgery. The Plan denied your request. The Plan says that without any additional clinical information this inpatient admission request has been denied.
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 has not submitted the requested case file. The Plan has not submitted medical records or documented that the Plan attempted to obtain the necessary medical records for review. Therefore, we decided that the Plan has to pre-approve the requested hospital services.
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 electrocardiographic recording up to 48 hours by continuous rhythm recording and storage (93226) provided on January 8, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for holter cardiac monitoring. You say that your in-network doctor ordered 48 hours holter monitoring. Before you received the monitor you called and made sure that the service will be covered. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for electrocardiographic recording up to 48 hours by continuous rhythm recording and storage (93226) provided on January 8, 2021 by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says the records do not support the need for 3 hours of therapy 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 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 physician reviewer found that you were admitted to the acute care hospital for surgical repair of a hip fracture after a fall. Your medical problems are stable. There are no complex nursing needs. You do not require treatment by multiple therapies in an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program.
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 pre-approve new eyeglass lenses (V2784, V2200) to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the eyeglass lenses. You say that you need a new prescription for your lenses and would like them to be covered by the Plan. The Plan denied your request. The Plan says while there is a supplemental benefit to cover routine vision care, these services can only be covered when they are received from an in-network provider. The provider requested in this case is not part of the Plan's network.
Medicare rules say that plans can require enrollees to get care from network providers. Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The contract with the Plan says that vision services must be received from an in-network provider. We looked at the file and the Plan's rules. The requested provider in this case is not a network provider with the Plan. Based on this information, we decided that the Plan's rules for coverage of the eyeglass lenses have not been met. Therefore, we decided that the Plan does not have to pre-approve new eyeglass lenses (V2784, V2200) to be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Opdivo (J9299).

You asked the Plan to pre-approve Opdivo. The Plan denied your request. The Plan says Opdivo (J9299) is not medically reasonable and necessary because it does not meet the criteria for off-label use of an FDA approved drug.

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 Opdivo. Our reviewer says that Opdivo (J9299) is not medically reasonable and necessary for the enrollee. Our physician reviewer found the requested use of Opdivo (J9299) is not FDA-approved for the enrollee's diagnosis. Opdivo is FDA-approved for residual disease after neoadjuvant treatment and surgery. Our reviewer found that the use of Opdivo is not supported by one of the major drug compendia or by clinical research that appears in a Centers for Medicare & Medicaid Services approved medical journal. Our physician reviewer also found that the use of Opdivo is not listed as not indicated, not supported or not recommended in any of the compendia.

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 have not been met. Therefore, we decided that the Plan does not have to pre-approve Opdivo (J9299).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bilateral lumbar facet joint injections.
You asked the Plan to pre-approve bilateral lumbar facet joint injections (64493, 64494). You say that your doctor is recommending the injections to neutralize some of your severe back pain. The Plan denied your request. The Plan says the clinical information provided does not meet criteria.
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 bilateral lumbar facet joint injections (64493, 64494). Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has other clear pain generators. Therefore, the criteria of the LCD are not met, and the request is considered not 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 bilateral lumbar facet joint injections(64493, 64494) have not been met. Therefore, we decided that the Plan does not have to pre-approve bilateral lumbar facet joint injections.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Tadalafil tablets.
You asked the Plan to pre-approve Tadalafil tablets. The Plan denied your request. The Plan says Tadalafil is a self-administered drug and does not fall under Part B coverage.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Tadalafil tablets.
Benefits for Tadalafil tablets may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy 45 minutes (S9122) provided March 8, 2021 to May 7, 2021.

You asked the Plan to pay for the psychotherapy services. You say that the enrollee required immediate assistance without knowing the provider who rendered home health services was not Medicare eligible. The Plan denied your request. The Plan says this provider is not a Medicare certified provider.

The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program. 

Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for the psychotherapy 45 minutes (S9122) provided March 8, 2021 to May 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve periodontal scaling and root planing (D4341), gingival irrigation (D4921) and an addition of a tooth to an existing partial (D5650).

You asked the Plan to pre-approve the dental services. You say that these services are necessary and affect your overall health. The Plan denied your request. The Plan says these services are not covered by your dental benefit.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve periodontal scaling and root planing (D4341), gingival irrigation (D4921) and an addition of a tooth to an existing partial (D5650).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy (PT) and occupational therapy (OT) to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve PT and OT to be provided by an OON provider. You say that the services are necessary. The Plan denied your request. The Plan says there are in-network providers that are able to provide these services. Therefore, coverage criteria have not been met.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 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. We found no exception that would require the Plan to pre-approve these items/services.
Therefore, we decided that the Plan does not have to pre-approve physical therapy (PT) and occupational therapy (OT) to be provided by an out-of-network (OON) provider
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a prolonged evaluation and management service (99358, 99359) provided on April 12, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for a prolonged evaluation and management service. You say that the services were medically necessary. The Plan denied your request. The Plan says services were provided by an out-of-network provider without prior authorization.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. The records provided for review do not show that the services at issue were urgent or emergent. 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 a prolonged evaluation and management service (99358, 99359) provided on April 12, 2021, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex Superion spacer.
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 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has chronic low back pain and lumbar spinal stenosis with neurogenic claudication. The records indicate multilevel disease and moderate to severe spinal stenosis at one of the requested levels. The criteria are not met and the Vertiflex device 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex Superion spacer.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs (11404) provided on May 10, 2021.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.
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 each outpatient hospital visit. You have been asked to pay a $250 copayment for the outpatient surgery provided. 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 excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs (11404) provided on May 10, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gemtesa tablets.

You asked the Plan to pre-approve Gemtesa tablets. You say that Gemtesa is the only suitable oral medication that the enrollee can tolerate. The Plan denied your request. The Plan says this drug is not covered for the enrollee's condition by Medicare Part B.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Gemtesa tablets.

Benefits for Gemtesa tablets may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the blood pressure monitor purchased on January 11, 2021.
You asked the Plan to reimburse you for automatic blood pressure monitor (A4670). You say that you want the Plan to reimburse you for the blood pressure monitor. The Plan denied your request. The Plan says there is no documentation of you receiving dialysis or having white coat hypertension.
The Plan must follow Medicare rules. The rules say that Medicare covers home blood pressure monitors only for enrollees who are on home dialysis, or those who meet the criteria for white coat hypertension and require ABPM to confirm a diagnosis of hypertension. The records do not show that this monitor is requested in the setting of home dialysis services, or that this request is for evaluation of suspected white coat hypertension. Although monitoring blood pressure in the home may be appropriate in this case, neither Medicare nor the Plan provides coverage of this item in this situation. Therefore, we decided that the Plan does not have to reimburse you for the blood pressure monitor purchased on January 11, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospitalization.

You asked the Plan to pay for acute inpatient hospital care. You say that the service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.

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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the record does not document that the treating physician has a reasonable expectation of a length of stay spanning two or more midnights. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Specifically, medically necessary services can be obtained in an observational level of care. This means acute inpatient hospitalization is not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospitalization.
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 admission. You say that IRF admission is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met.
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 the complexity of the nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.
The records show you were admitted for shortness of breath, possible pneumonia and acute kidney injury. Medical problems are stable. There are no complex nursing or rehabilitation needs. The medical records do not show that you require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. There is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home delivered meals (S5170).
You asked the Plan to pre-approve the home delivered meals. You say that you say that the enrollee must consume pureed foods only to avoid aspiration. The Plan denied your request. The Plan says you do not meet the coverage criteria.
The Plan must follow Medicare rules. Medicare rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. We looked at the file and Medicare rules. The record does not show that you meet Plan criteria because there is no indication you were recently discharged from a hospital due to congestive heart failure. Based on this information, we decided that Medicare rules for coverage of the home delivered meals have not been met. Therefore, we decided that the Plan does not have to pre-approve home delivered meals (S5170).