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

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve the SNF admission. You say that the enrollee would benefit from SNF care to allow her to regain additional strength so that she can get back to caring for herself. The Plan denied your request. The Plan says the enrollee's needs are mainly custodial and she is not likely to receive benefit from daily skilled therapy due to her cognitive issues/dementia.
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 the SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee was a female with a history of dementia who was admitted to the hospital on 7/6 for altered mental status. Prior to hospital admission, the patient required assistance with all ADL's and personal care. In addition to dementia, the patient also carries a diagnosis of hypertension, diabetes, anxiety, and a history of kidney cancer. During her hospitalization, the patient did not receive any further significant treatment modalities including no further antibiotics. Physical therapy revealed the patient is able to ambulate 15 feet with minimal assistance. She was always noted to be confused requiring redirection which is her baseline at home. Furthermore, she required only minimal assistance with bed mobility and transfers.
The patient does not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse required to safely and effectively provide medically necessary and reasonable treatment in a SNF. She does not have complex wound care or other ongoing SNF level SN need. Her functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment only in a SNF. She does not require skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis" in a SNF. As a practical matter, this patient does not require the necessary services on 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 admission to a skilled nursing facility (SNF).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve intensity modulated radiation therapy (IMRT).You asked the Plan to pre-approve intensity modulated radiation therapy. You say that the services are necessary.The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not been met.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve intensity modulated radiation therapy. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found IMRT is not experimental, but rather a useful tool available to radiation oncologists to potentially reduce toxicity and improve the dose distribution in patients when the dose-volume exposure of normal tissues warrants its use. ASTRO's position is that IMRT is necessary when the need is sufficiently supported. Adequate justification for IMRT is not provided in this case.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of intensity modulated radiation therapy have not been met.Therefore, we decided that the Plan does not have to pre-approve intensity modulated radiation therapy (IMRT).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the laboratory work provided on January 7, 2020 and February 6, 2020.
You asked the Plan to waive the copayments for the laboratory work. You say that you have never had to pay for this service in the past. You say you need this service done regularly as a stroke victim. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 copayment per visit for laboratory tests, non-radiological tests, flat film x-rays, and ultrasounds. For each date of service, you have been asked to pay the allowed amount of the claim because these amounts are less than the $20 copayment for the laboratory work.
You have been asked to pay a $7.37 copayment for the laboratory work on each date of service. The laboratory work falls within the "Outpatient diagnostic tests and therapeutic services and supplies" 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 copayments for the laboratory work provided on January 7, 2020 and February 6, 2020.
Our decision is only about the 2020 services. If you have any questions about prior years billing, please contact the plan directly.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve transcatheter placement of intravascular stent (37215).You asked the Plan to pre-approve transcatheter placement of intravascular stent. You say that the services are necessary.The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not been met.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve transcatheter placement of intravascular stent. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found based on the records the enrollee has a severe asymptomatic carotid stenosis. In this circumstance there are no documented high risk features such as prior neck radiation, contralateral carotid stenosis, prior neck surgery, transient ischemic attack (TIA) symptoms, congestive heart failure, unstable angina or advanced age that would increase risk with carotid endarterectomy. Therefore the records do not support the medical necessity for carotid stenting.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of transcatheter placement of intravascular stent have not been met.Therefore, we decided that the Plan does not have to pre-approve transcatheter placement of intravascular stent (37215).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the clinical crown lengthening (D4249) provided on March 11, 2020.You asked the Plan to pay for the clinical crown lengthening. You say that the benefit highlight brochure states that dental comprehensive services have a $0 copay, or have a 50% coinsurance. You also say that you believe the clinical crown lengthening should qualify for some comprehensive dental service.The Plan denied your request. The Plan says this service is clearly excluded from your plan.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 pay for the clinical crown lengthening (D4249) provided on March 11, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveRuxience.You asked the Plan to pre-approveRuxience. You say that the medication is necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Ruxience. Our reviewer says that the medication is not medically necessary. Our physician reviewer found the submitted documentation does not state the CD20 status nor does it include information about planned chemotherapy in combination with Ruxience. Therefore, the documentation does not support that Ruxience is medically reasonable and necessary or 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 Ruxience have not been met.Therefore, we decided that the Plan does not have to pre-approveRuxience.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a CT scan of the thorax.You asked the Plan to pre-approve a CT scan. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says that the requested CT scan is not medically necessary.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 a CT scan. Our reviewer says that the documentation does support that the requested CT scan is medically reasonable or necessary. Our physician reviewer found the enrollee has resected stage III thymoma. A CT scan is allowed every 6-12 months for two years per NCCN guidelines. Therefore, the enrollee meets criteria for the requested CT scan.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 CT scan have not been met.Therefore, we decided that the Plan has to pre-approve a CT scan of the thorax.If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea mammoplasty augmentation (19325).You asked the Plan to pre-approvethe mammoplasty augmentation. You say that the service is medically necessary.The Plan denied your request. The Plan says the procedure is cosmetic in nature and not covered.The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are coverable.  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 mammoplasty augmentation. Our reviewer says that the requested procedure is not medically necessary. Our reviewer found the documentation supports that the requested revision of bilateral breast reconstruction is cosmetic, as the enrollee is unhappy aesthetically with the appearance of her breast. The rules say that cosmetic surgery and related services, except as required for the prompt repair of accidental injury or to improve the functioning of a malformed body member, is not covered.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided thatMedicare rules for coverage of the mammoplasty augmentation have not been met.Therefore, we decided that the Plan does not have to pre-approvea mammoplasty augmentation (19325)
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for Magnetic Resonance Imaging (MRI) of the Heart (75561) provided January 17, 2020.
You asked the Plan to waive the copayment for the MRI. You say that the copayment should be waived. The Plan denied your request. The Plan says the correct copayment was applied.
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 $300 copayment for Diagnostic Radiology. You have been asked to pay a $300 copayment for the MRI. The MRI falls within the Diagnostic Radiology 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 Magnetic Resonance Imaging (MRI) of the Heart (75561) provided January 17, 2020.
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 the inpatient psychiatric services. You say that the records provided support the need for continued inpatient psychiatric services.The Plan denied your request. The Plan says the enrollee no longer meets the criteria for this level of care.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 the inpatient psychiatric services. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee was admitted to the acute inpatient psychiatric hospitalization on July 2, 2020 with Schizoaffective Disorder Bipolar Type. Based upon review the records provided it was not expected this enrollee would improve in a reasonable period of time for the dates in question as she did not have suicidal or homicidal ideation noted and denied any auditory or visual hallucinations. The enrollee was compliant with treatment while not showing any acute threats to safety. 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 she did not have dangerousness to self or others but was compliant with her treatment.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 inpatient psychiatric services have not been met.Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve admission to a SNF. You say that the requested admission to a SNF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF admission.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed 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 admission to a SNF. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to acute care on 7/11/20 for the diagnosis of malignant neoplasm of cerebral meninges and essential hypertension. From a nursing perspective, the enrollee received oral and ophthalmic medications. The enrollee had stable vital signs. He was alert with confusion. The plan was for palliative care and then Hospice. Regarding rehabilitation services, the enrollee received physical therapy and occupational therapy in the hospital. He required maximal assist of 2 for bed mobility and transfers. He required varying assist with activities of daily living. There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. This enrollee does 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 admission to a SNF have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound of the abdomen (76700) provided January 6, 2020.
You asked the Plan to waive the copayment for the ultrasound. You say that the copayment should be waived. The Plan denied your request. The Plan says the correct copay was applied.
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 $135 copayment for Diagnostic Radiology services. You have been asked to pay a $110.93 copayment for the ultrasound. The ultrasound falls within the Diagnostic Radiology services benefit category. In this case, the allowable amount is less than the $135 copayment noted in the contract. 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 an ultrasound of the abdomen (76700) provided January 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe two surface anterior resin-based composite (D2331), two anterior four or more surfaces or involving incisal angle resin-based composites (D2335 x2), and posterior two surface resin-based composite (D2392) provided on February 4, 2020.You asked the Plan to pay forthe resin-based composites. You say that you were informed that these services would be paid for.The Plan denied your request. The Plan says these services are not covered by the Plan. The Plan also says that you did not elect to purchase an optional supplemental benefit plan.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 pay forthe two surface anterior resin-based composite (D2331), two anterior four or more surfaces or involving incisal angle resin-based composites (D2335 x2), and posterior two surface resin-based composite (D2392) provided on February 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve medical services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the OON services. You say that this doctor has been treating you for at least 10 years. The Plan denied your request. The Plan says there are providers available in your network.
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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve medical services 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 600MCG Belbuca.
You asked the Plan to pre-approve the Belbuca. You say that you would like reconsideration because this drug is medically necessary for the treatment of the member's condition. The Plan denied your request. The Plan says this medication falls under Part D 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 600MCG Belbuca.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Emgality (J3590).
You asked the Plan to pre-approve the Emgality. 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 Emgality (J3590).
Benefits for Emgality may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.