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

We decided that the Plan does not have to pre-approve Hyaluronan or derivative, Monovisc (J7327).
You asked the Plan to pre-approve Hyaluronan or derivative, Monovisc. The Plan denied your request. The Plan says the documentation does not show trial and failure, intolerance, or other clinical reason not to use the preferred product, Synvisc-one.
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 Hyaluronan or derivative, Monovisc. Our reviewer says that Hyaluronan or derivative, Monovisc does not meet coverage criteria. Our physician reviewer found based on the medical records provided you have not tried and failed the required drug, Synvisc-One. Our reviewer also found that there is no indication that the Plan's required drug would likely be less effective and/or likely have adverse effects for you. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Hyaluronan or derivative, Monovisc have not been met. Therefore, we decided that the Plan does not have to pre-approve Hyaluronan or derivative, Monovisc (J7327).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda (J9271).

You asked the Plan to pre-approve Keytruda. The Plan denied your request. The Plan says the enrollee's test results do not show that the enrollee's tumor cells have high levels of microsatellite (MSI-H) instability, or deficient mismatch repair (dMMR). The Plan also says that the enrollee's test results do not show that the enrollee's tumor cells have high levels of tumor mutational burden.

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. Our reviewer says that Keytruda (J9271) is not medically reasonable and necessary for the enrollee. Our physician reviewer found the requested use of Keytruda (J9271) is not FDA-approved for the enrollee's diagnosis. Our reviewer found that the use is not supported by one of the major drug compendia or by clinical research that appears in a Centers for Medicare & Medicaid Services (CMS) approved medical journal. Our physician reviewer also found that the use of Keytruda 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 Keytruda have not been met. Therefore, we decided that the Plan does not have to pre-approve Keytruda (J9271).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a WATS3D biopsy (88361, 83305) provided on January 6, 2021.
You asked the Plan to pay for a WATS3D biopsy. You say that this should be covered. The Plan denied your request. The Plan says this was 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 pay for a WATS3D biopsy. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the submitted medical records do not support the high likelihood of Barrett's esophagus. Therefore, the enrollee does not meet the American Society for Gastrointestinal Endoscopy guidance on the use of WATS-3D. 
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 WATS3D biopsy have not been met. Therefore, we decided that the Plan does not have to pay for a WATS3D biopsy (88361, 83305) provided on January 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a telehealth office visit with a specialist (99213) provided on January 5, 2021.
You asked the Plan to waive the copayment for a telehealth office visit. You say that your visit with the specialist was over the phone and you should not have to pay a copayment. The Plan denied your request. The Plan says the copayment you are being charged is correct.
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 $40 copayment for physician/practitioner services, including doctor's office visits with a specialist.
You have been asked to pay a $40 copayment for a telehealth office visit with a specialist. The EOC confirms that $40 is the required copayment for this service. Telehealth office visits fall within the physician/practitioner services, including doctor's office visits 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 a telehealth office visit with a specialist (99213) provided on January 5, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission and services.

You asked the Plan to pre-approve SNF services. You say that you are not able to walk on your own. The Plan denied your request. The Plan says you do not require a skilled therapist on a daily basis.

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 services. Our physician reviewer found from a nursing perspective, you received oral medications, had stable vital signs, and was treated for pain. There are no identifiable skilled nursing service needs. Regarding rehab services, you are at a minimal assist level with functional mobility and are non-ambulatory due to weight-bearing restrictions. There are no identifiable skilled therapy service needs. You do not require skilled nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission and services.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve retainer crowns (D6740) for tooth #'s 13 and 15, and pontic
(D6245) for tooth #14.

You asked the Plan to pre-approve the retainer crowns and pontic. You say that you would like these services
to be reconsidered for coverage. The Plan denied your request. The Plan says that the documentation does not
support the need because outdated x-rays were provided.

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. The Plan covers the retainer
crowns and pontic when the services are medically necessary and reasonable.

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 retainer crowns and pontic. Our
reviewer says that the documentation provided is current and meets the criteria for coverage for a fixed bridge
replacing tooth #14 with a pontic using tooth #'s 13 and 15 as abutment retainers. Our physician reviewer found
the dental record and radiographs indicate that the radiographs provided were dated April 6, 2021. Our
reviewer found that these x-rays are up to date and provide the required documentation needed.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
the Plan's rules for coverage of the retainer crowns and pontic have been met. Therefore, we decided that the
Plan has to pre-approve retainer crowns (D6740) for tooth #'s 13 and 15, and pontic (D6245) for tooth #14.

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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (97530) provided on March 2, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services cannot be verified.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 97530 is "Therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes". We asked our coding reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the use of code 97530 is not supported by the records provided. Our coding reviewer found that an occupational therapist is considered a qualified health care professional, however, the therapist visit does not include time spent with each function treated, therefore CPT 97530 cannot be confirmed as performed. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the services (97530) provided on March 2, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ten (10) additional PT visits.

You asked the Plan to pre-approve ten (10) additional PT visits. The Plan denied your request. The Plan says ten (10) additional PT visits are not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 

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 ten (10) additional PT visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found that in this case, the enrollee has previously been treated with outpatient therapies and should be independent with a home exercise program. The additional therapy services are not an appropriate duration and frequency for treatment of the enrollee's medical condition and therefore are not 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 ten (10) additional PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve ten (10) additional PT visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency room (ER) services provided on November 13, 2020.

You asked the Plan to pay for the emergency room services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.

The Plan must follow Medicare rules. Medicare rules say that freestanding ER services are only covered if the ER clinic is affiliated with a hospital.

We looked at the file and Medicare rules. The file shows that the emergency room services were provided to the enrollee on November 13, 2020. This facility is considered a freestanding ER. This facility is not affiliated with a hospital. Based on this information, we decided that Medicare rules for coverage of the emergency room services have not been met. Therefore, we decided that the Plan does not have to pay for the emergency room (ER) services provided on November 13, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from November 4, 2019, to
November 5, 2019.
You asked the Plan to pay for the acute inpatient hospital care. The Plan denied your request. The Plan says
that inpatient care was 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 the acute inpatient hospital care. Our
reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our
physician reviewer found that the enrollee had a history of congestive heart failure, atrial fibrillation,
hypertension and hyperlipidemia, who was admitted for acute cardiac syndrome, hypotension, and acute kidney
injury. The records indicate that the treating physician had a reasonable expectation of a length of stay
spanning 2 or more midnights. The enrollee had unanticipated recovery in spite of his presenting clinical
scenario.
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 acute inpatient hospital care have been met. Therefore, we decided that the
Plan has to pay for the acute inpatient hospital care provided from November 4, 2019, to November 5, 2019.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the complete maxillary denture (D5110) and complete mandibular denture (D5120).
You asked the Plan to pre-approve the complete maxillary denture and complete mandibular denture. You say that you would like these dentures to be approved for coverage. The Plan denied your request. The Plan says these services are not covered under your benefit package.
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 the complete maxillary denture (D5110) and complete mandibular denture (D5120).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a stress transthoracic echocardiography
(TTE) test (93351) provided on August 28, 2020.
You asked the Plan to waive the coinsurance for a stress TTE test. You say that you need an extension for the
doctor's visit claim that was received late and have made payment for. You also say that you believe you met
your deductible if the bill was processed on time and not until January. The Plan denied your request. The Plan
says the coinsurance you are being charged is correct.
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 outpatient diagnostic tests and therapeutic services and supplies. Your contract with he Plan
also clearly says that you must pay a 20% coinsurance up to a copayment maximum of $250.
You have been asked to pay a 20% coinsurance for a stress TTE test. The allowed amount of the claim is
$442.52, resulting in a coinsurance obligation of $88.50. The EOC confirms that 20% is the required
coinsurance for this service. A stress TTE test falls within the outpatient diagnostic tests and therapeutic
services and supplies benefit category. Please note, the Plan has indicated that your appeal regarding your
deductible for services rendered on another date of service has been handled separately. Please contact the Plan
for information about this case. 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 coinsurance for a stress transthoracic
echocardiography (TTE) test (93351) provided on August 28, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an interspinous spacer device.

You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says this device has not been shown to be safe and effective in long term studies.

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 requested services. Our physician reviewer found that the interspinous spacer device is experimental. More research is needed to show safety and efficacy of the device. Therefore, the requested services are 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 the requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve an interspinous spacer device.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia.You asked the Plan to pre-approve Prolia. The Plan denied your request. The Plan says the enrollee has not tried and failed zoledronic acid or have a history of osteoporotic fracture.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 Prolia. Our physician reviewer found that the Plan requires a trial of zoledronic acidor have a history of osteoporotic fracture before they will approve the requested drug. The enrollee has age related osteoporosis without pathologic fracture. The record indicates that the requested drug is a new start. She has not tried and failed zoledronic acid. There is not a sufficient medical rationale why the plan's formulary preferred step one agent is not appropriate 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 Prolia have not been met.Therefore, we decided that the Plan does not have to pre-approve Prolia.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an axial rotation unit (L5986), a flex-walk system (L5981), and a protective outer surface covering system (L5962).You asked the Plan to pre-approve an axial rotation unit, a flex-walk system, and a protective outer surface covering system. You say that these items are medically necessary.The Plan denied your request. The Plan says these items would exceed the enrollee's needs.The Plan follows Medicare rules. Medicare rules say that a flex-walk system is covered for beneficiaries whose functional level is 3 or above.Protective outer surface covering systems are used by a beneficiary who has special needs for protection against unusually harsh environmental situations where it is necessary to protect the lower limb prosthesis.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 an axial rotation unit, a flex-walk system, and a protective outer surface covering system. Our reviewer says that the requirements for coverage of the requested items have not been met. Our physician reviewer found the flex-walk system exceeds the patient's medical needs as the submitted records do not support that the patient's functional level is at a K3 or above. The axial rotation unit is part of a foot that must be paired with a complete foot based on the patient's functional level. The records provided do not indicate that the patient is exposed to harsh conditions or engages in extraordinary activities that require extra protection from a specialized prosthetic cover. A standard prosthetic cover is sufficient for everyday use.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an axial rotation unit, a flex-walk system, and a protective outer surface covering system have not been met.Therefore, we decided that the Plan does not have to pre-approve an axial rotation unit (L5986), a flex-walksystem (L5981), and a protective outer surface covering system (L5962).