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

We decided that the Plan does not have to pre-approve Hymovis (J7322).
You asked the Plan to pre-approve Hymovis. You say that the Hymovis is medically necessary. The Plan denied your request. The Plan says a trial of Orthovisc and Monovisc is required before alternatives can be considered.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 Hymovis. Our reviewer says that coverage criteria for Hymovis has not been met. Our physician reviewer found the enrollee has not trialed plan preferred viscosupplemental treatments such as Orthovisc and Monovisc. Step therapy, as outlined by the plan, requires these be trialed first. Nothing in the record shows that these treatments would be unsafe or ineffective. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Hymovis have not been met. Therefore, we decided that the Plan does not have to pre-approve Hymovis (J7322).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a low dose CT scan for lung cancer screening for the enrollee.
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your request. The Plan says the clinical information provided does not meet all of the criteria.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the scan. Our reviewer says that the requested scan is not medically reasonable or necessary. Our physician reviewer found the enrollee clearly has indications for CT surveillance based upon Fleischner criteria in light of the 7 mm nodules and the smoking history placing him in a high risk category. CT of the chest to follow the nodules would be appropriate but since the prior exams have been abnormal and since the prior exams have shown evidence of COPD a conventional CT of the chest in lieu of a low dose lung CT would be appropriate. The plan has indicated a conventional scan would be approved, but the low dose scan cannot be approved.
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 scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a low dose CT scan for lung cancer screening for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission. You asked the Plan to pre-approve these services. You say that you have lost energy and stamina. The Plan denied your request. The Plan says the admission is 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 pre-approve these services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the records show that you were admitted to the hospital on May 12, 2020 with swelling of the tongue. You received oral medications and had stable vital signs. You were effectively treated for pain. You received physical, occupational, and speech therapy in the hospital. You need assistance with walking 120 feet with a rolling walker and varied assistance with activities of daily living. You are tolerating a regular diet. You have no skilled nursing needs. You have skilled therapy needs but do not require skilled therapy on a daily basis. As a practical matter, you do not require the necessary services on an inpatient basis at the SNF 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that you are appealing.The Plan denied your request. The Plan says the denial of authorization for IRF service is correct.The Plan must follow Medicarerules. 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 wascorrect 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 enrollee's nursing,medical, and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's current medical status does not require intensive physician or nursing oversight in an IRF. Whilethe enrollee may benefit from additional therapies, the enrollee's functional level does not require or indicate that this therapy must be in an IRF with an intensive level 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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve TTFT.
You asked the Plan to pre-approve TTFT. You say that you would like reconsideration because this is the only
promising option for the member. The Plan denied your request. The Plan says TTFT is not covered by
Medicare in absence of continued benefit.
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 TTFT. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found the member's most recent MRIs showed evidence of disease progression. In as much the
requirements of the LCD for coverage were not met.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of TTFT have not been met. Therefore, we decided that the Plan does not have to
pre-approve TTFT.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approvemagnetic resonance imaging (MRI) of the temporomandibular joint (TMJ).You asked the Plan to pre-approvethese services. You say that the enrollee has severe pain in the right TMJ.The Plan denied your request. The Plan says that the services are not medically necessary.The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are medically necessary. Our physician reviewer found the enrollee is noted to have right jaw pain attributed to TMJ syndrome. The enrollee has been seen by her primary care physician, an emergency physician, an integrative medicine physician, her dentist and a physical therapist to address this issue. She has tried treatments such as over-the-counter medications, prescription medications, osteopathic manipulation, home exercise and physical therapy with incomplete relief of her pain. Additional diagnostics seem reasonable, to assure the clinical diagnosis is correct and to evaluate for any issues which may require surgical correction. The documentation supports that the requested MRI is medically necessary and reasonable.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have been met.Therefore, we decided that the Plan has to pre-approvemagnetic resonance imaging (MRI) of the temporomandibular joint (TMJ).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient mental health care from June 8, 2019 to June 13, 2019.You asked the Plan to pay for inpatient mental health care. You say that this was medically necessary. The Plan denied your request. The Plan says the enrollee was no longer at risk of harm for the dates in question.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 pay for inpatient mental health care. Our reviewer says that the inpatient care at issue was not medically necessary. Our physician reviewer found based on the records provided it was not expected this enrollee would improve in a reasonable period of time beyond the approved dates as he was not showing any dangerousness to self or others, auditory or visual hallucinations and without aggressive behaviors. It did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the dates in question as he did not have any suicidal or homicidal thoughts, auditory or visual hallucinations or abnormal behaviors.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient mental health care have not been met.Therefore, we decided that the Plan does not have to pay for inpatient mental health care from June 8, 2019 to June 13, 2019.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for x-rays of the abdomen (74018) provided on January 25, 2020.You asked the Plan to pay for the x-rays. You say that you would like reconsideration because no one else should have billed or been paid for this procedure.The Plan denied your request. The Plan says that services that are considered column II procedures to another service are not eligible for reimbursement when billed with column I procedure code.The Plan must follow Medicare rules. Medicare rules say that all line items for the same beneficiary, same NPI, and same date of service shall be subject to NCCI procedure-to-procedure (PTP) edits.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the x-rays have been met.Specifically, the record indicates that the provider who rendered the column I procedure has a different NPI than the provider who rendered the column II procedure. Therefore, we decided that the Plan has to pay for x-rays of the abdomen (74018) provided on January 25, 2020.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-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF 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 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 services are not medically necessary. Our physician reviewer found the enrollee was admitted to the hospital on May 2, 2020 with back pain. She had fractures of the hip socket and pelvis. Non-operative treatment was recommended. She is walking short distances with a wheeled walker. She has no complex needs that require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. She may benefit from further therapy but does not require an intensive therapy program 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-approveacute inpatient rehabilitation facility (IRF) admission and services.
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 the enrollee requires the level of care present in the LTACH facility. The Plan denied your request. The Plan says the enrollee's condition can be managed in a lower level of care.
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 patient is currently undergoing treatment at an ACH for diverticulitis, in the setting of severe dementia. The enrollee is not intubated/ventilated. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs 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 ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing LTC 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for additional 1-day stay, for the enrollee.
You asked the Plan to pay for additional 1-day stay. You say that the stay was medically necessary. The Plan denied your request. The Plan says the stay 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 additional 1-day stay. 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 review has determined that the medical records provided did not meet medical necessity for the additional 1-day stay. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of additional 1-day stay have not been met. Therefore, we decided that the Plan does not have to pay for additional 1-day stay, for the enrollee.
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 the records provided support the need for LTACH care. The Plan denied your request. The Plan says the enrollee does not meet the guidelines for coverage of LTACH care.
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 medical records provided show that the short term acute care hospital is able to provide all of the services the enrollee has been receiving since May 5, 2020. The enrollee would have been able to receive the same level of care in the short term acute care hospital. The enrollee was stable to transfer to a lower level of care such as an inpatient rehabilitation facility, a skilled nursing facility, a sub-acute rehabilitation facility, or home with home health services. 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the eye exam rendered on January 14, 2020.You asked the Plan to waive the copayment for these services. You say that you do not feel you owe the copayment.The Plan denied your request. The Plan says the copayment was applied 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 $25 copayment per visit for Medicare-covered exams to diagnose and treat diseases of the eye. You have been asked to pay a $25 copayment per visit for these services. These services falls within the Medicare-covered exams to diagnose and treat diseases of the eye 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 the eye exam rendered on January 14, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda/Pembrolizumab for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says this drug is used as first-line, single-agent treatment if the patient does not have certain tumor aberrations, EGFR, or ALK.
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 drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found the submitted documentation does not include results for EGFR, ALK, ROS1, BRAF, MET or RET testing. There is no indication that such testing, including plasma testing, is not possible. The FDA and compendia support for using Keytruda as monotherapy for first line treatment in NSCLC state as a minimum EGFR and ALK mutations should be negative. The NCCN compendium specifically states: if there is insufficient tissue to allow testing for all of EGFR, ALK, ROS1, BRAF, MET and RET, repeat biopsy and/or plasma testing should be done. If these are not feasible, treatment is guided by available results and, if unknown, these patients are treated as though they do not have driver oncogenes. Therefore the documentation does not support that Keytruda is medically reasonable and necessary nor that it 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 drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Keytruda/Pembrolizumab for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing for the office visit and Part B drugs rendered on January 15, 2020.
You asked the Plan to waive the cost sharing for these services. You say that the cost sharing was not disclosed prior to you receiving the services. The Plan denied your request. The Plan says the cost sharing was applied 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 20% coinsurance for Part B drugs administered by a provider and a $50 copayment for specialist visits.
Review of the file shows that you received Medicare Part B covered drugs on January 15, 2020. You have been asked to pay a 20% coinsurance for these services, for a total of $264. These services fall within the Part B drugs administered by a provider benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan.
The file shows that you received specialist services on January 15, 2020. You have been asked to pay a $50 copayment for these services. These services fall within the specialist visits benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan.
The total amount you have been asked to pay for these services is $314. 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 cost sharing for the office visit and Part B drugs rendered on January 15, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea tier exception for Tacrolimus.You asked the Plan to pre-approvethese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the drug is not eligible for a tier exception.The Plan must follow Medicare rules. The rules say that Part B drugs are not eligible for Part D tier exceptions.We looked at the file and Medicare rules. The request is for tacrolimus at a tier exception. This is a Part B drug and is therefore not eligible for a tier exception.Therefore, we decided that the Plan does not have to pre-approvea tier exception for Tacrolimus.