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

We decided that the Plan has to pre-approve the SNF care.
You asked the Plan to pre-approve SNF care. You say that the enrollee has had an amputation above the knee, and needs rehabilitation to gain strength, mobility, and to stabilize his blood pressure. You also say that the enrollee's doctors say he needs SNF care to help improve his mobility skills because he is getting weaker by the day. The Plan denied your request. The Plan says that this request does not meet Medicare guidelines because there are no noted skilled nursing or therapy needs that need to be provided on a daily basis as an inpatient only status.
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 the SNF services are medically reasonable and necessary for the enrollee. Our physician reviewer found the enrollee does not have documented skilled nursing needs. The enrollee does have documented skilled therapy needs. Our reviewer found that the enrollee appears to be functioning below his baseline, after several recent hospitalizations. Daily skilled services are required to establish a maintenance program and/or to prevent deterioration of the enrollee's condition. Our physician reviewer also found that at this point, the enrollee's care needs, as a practical matter, cannot be provided 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 SNF care have been met. The Plan must continue coverage for the SNF skilled service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve the SNF care.
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 the Vertiflex device for the enrollee.

You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your
request. The Plan says a review of the current medical literature indicates that this service is considered
experimental and investigational.

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 the device. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found the device is experimental. More research is needed to show safety and efficacy of the device.

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 device have not been met. Therefore, we decided that the Plan does not have
to pre-approve the Vertiflex device for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the consultation to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the out-of-network consultation. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says records received do not indicate that you have an emergent or urgent medical condition, are in need of specialized services that are not available in the network, or have an authorization from your plan.
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 the consultation to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric services.
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. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 was admitted to the
hospital on August 9, 2021 with post-traumatic stress disorder and recurrent severe major depressive disorder without psychotic features. Based on the submitted records, it is not expected that he will improve in a reasonable period of time beyond the dates in question, as he is not showing dangerousness to self or others and has no aggressive behaviors. He has no auditory or visual hallucinations. It does not appear that active treatment is taking place. The inpatient services are therefore 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 inpatient psychiatric services.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve BRCA1 and BRCA2 genetic testing.
You asked the Plan to pre-approve BRCA1 and BRCA2 genetic testing. You say that this is medically necessary due to the enrollee's family history. The Plan denied your request. The Plan says the enrollee does not meet the requirements for coverage.
The Plan must follow Medicare rules. Medicare rules say that BRCA 1 and BRCA 2 testing are covered for enrollees with a diagnosis or personal history of specific cancers as detailed in the LCD. We looked at the file and Medicare rules. The records do not show that the enrollee has a diagnosis or personal history of cancer. Based on this information, we decided that Medicare rules for coverage of BRCA1 and BRCA2 genetic testing have not been met. Therefore, we decided that the Plan does not have to pre-approve BRCA1 and BRCA2 genetic testing
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 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. 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 medically necessary. Our physician reviewer found you were admitted to the hospital for Coronavirus pneumonia and sepsis from an infected dialysis catheter. You were discharged home on August 3, 2021 and remain weak with falling episodes. You are medically stable with no complex nursing or
rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or
occupational therapy, and 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. 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair (K0813).

You asked the Plan to pre-approve a power wheelchair. You say that your current wheelchair needs repairs, and you are waiting for the shop to receive a needed part. The Plan denied your request. The Plan says a second wheelchair is not covered.

The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. 

The file shows that you have a power wheelchair. The record does not show that your current wheelchair has irreparable wear or damage. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair (K0813).
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 you need inpatient rehabilitation because it is not
safe for you to return home yet. The Plan denied your request. The Plan says the criteria for an IRF are not met.
You can safely receive the services you need in other settings.
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 based on your current medical stability and lack of medical complexity, there is
no need for physician supervision at least three times per week for the ongoing management of any active or
acute exacerbations of chronic medical conditions. There are no documented acute rehab nursing needs. There
is no evidence of indication for an intensive therapy program with three hours of therapy per day with frequent
physician oversight and an interdisciplinary approach to rehabilitation care. Documentation does not support
the need for IRF care. Your rehab needs can safely be met in a less intensive 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 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic services provided on April 28, 2021, to May 14, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for chiropractic services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by a participating provider. The Plan says that there are in-network providers available for these services.
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 chiropractic services provided on April 28, 2021, to May 14, 2021 by an out-of-network (OON) provider
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99204) and the x-ray exam of the knee (73504) rendered by the out-of-network (OON) providers on May 12, 2021.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by out of network providers, 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 providers in this case are not network providers with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal.
The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the office visit (99204) and the x-ray exam of the knee (73504) rendered by the out-of-network (OON) providers on May 12, 2021
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable ventilator (E0466).
You asked the Plan to pre-approve a portable ventilator. You say that this is medically necessary. The Plan denied your request. The Plan says you can be treated with a bi-level positive airway pressure device.
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. 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 portable ventilator. Our reviewer says that the requested portable ventilator is not medically necessary in this case. Our physician reviewer found although a diagnosis of chronic obstructive pulmonary disease is listed in the records, there are no pulmonary function test results to confirm. You also have obesity-hypoventilation syndrome (OHS), which may be the major cause of the carbon dioxide retention and is not a diagnosis for which a ventilator is covered. It is most appropriately treated with a positive airway pressure device.
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 portable ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a portable ventilator (E0466).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the SNF admission.
You asked the Plan to pre-approve the SNF admission. You say that you would like reconsideration because the admission is medically necessary in order for you to regain independence. The Plan denied your request. The Plan says your rehabilitation and medical needs may be met in a lower level of care.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed 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 the SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do 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 admission have not been met. Therefore, we decided that the Plan does not have to pre-approve the SNF admission.
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 you will continue to decline without IRF care. You need these services to regain strength and return to a sense of normalcy. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. You can safely receive the services you need in another setting.

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 the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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. 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99214) rendered by the out-of-network
(OON) provider on February 4, 2020.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the service was rendered 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 provider in this case is not a network provider with the Plan. The Plan had network providers available
who could have provided the service at issue in this appeal.
The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for
this service. Therefore, we decided that the Plan does not have to pay for the office visit (99214) rendered by
the out-of-network (OON) provider on February 4, 2020
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Dupixen solution pen injectors.
You asked the Plan to pre-approve self-administered drug. You say that you are appealing this denial. The Plan denied your request. The Plan says this drug is not covered by Medicare Part B and the Plan does not administer the enrollee's Medicare Part D prescription drug benefits.
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 Dupixen solution pen injectors.
Benefits for self-administered drug 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 300mg Entyvio.

You asked the Plan to pre-approve 300mg Entyvio. You say that you would like reconsideration because the
requested drug is medically necessary. The Plan denied your request. The Plan says the clinical value and
effectiveness of Entyvio in the setting of refractory microscopic colitis has not been demonstrated in the peer-reviewed
literature.

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 300mg Entyvio. Our reviewer says that
the requested use of Entyvio is not FDA-approved for the enrollee's diagnosis. Our physician reviewer found
its use 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 300mg Entyvio have not been met. Therefore, we decided that the Plan does not
have to pre-approve 300mg Entyvio.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the lab services you had on March 31, 2021.
You asked the Plan to waive the copayment for the lab services. You say that you believe that because these labs were needed as a result of you annual physical, they should be covered 100%. The Plan denied your request. The Plan says you were charged this copayment correctly.
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 $10 copayment for lab services (other than fecal immunochemical tests).
You have been asked to pay a $10 copayment for the lab services. According to your Evidence of Coverage, an annual physical exam only includes a bodily systems evaluation, measurement and recording of vital signs, a complete medication review, and a review of recent hospitalizations. It does not include lab services. 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 lab services you had on March 31, 2021.