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

We decided that the Plandoes not haveto pre-approvethe CardioMEMS HF system for the enrollee.You asked the Planto pre-approvethe system. You say that this is medically necessary.The Plandenied your request. The Plansaysmedical studies have not proven that this device is helpful for treatment of the health problem.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 system. Our reviewer says that the requested system is not considered medically reasonable and necessary in this case. Our physician reviewer found in this circumstance therapy changebased on data obtained from a CardioMEMs device has been demonstrated in only one randomized prospective trial to help reduce hospital readmission compared to standard medical therapy. Moreover, concerns have been raised about potential bias in this trialcalling into question the results. Therefore,the efficacy of the CardioMEMS device is uncertain at this time according to leading authorities and not recommended in current guidelines for the treatment of heart failure. Medicare coverage criteria are not met since the device should still be considered experimental or investigational.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 system have not been met.Therefore, we decided that the Plandoes not haveto pre-approvethe CardioMEMS HF system for the enrollee
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (D2740), core build up (D2950), a partial lower denture (D5212), and an occlusal guard (D9945).
You asked the Plan to pre-approve the crown, core build up, partial denture and occlusal guard. You say that the services are necessary. The Plan denied your request. The Plan says the requested dental services and items are not listed as covered.
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 a crown (D2740), core build up (D2950), a partial lower denture (D5212), and an occlusal guard (D9945).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says the services can be safely received in other settings, for example: a skilled nursing facility.
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 requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the intensity of services provided at an IRF is not required. Specifically, you are not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. Your care needs can be met at a lower level of care, such as SNF/SAR. 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 admission to an inpatient rehabilitation facility (IRF).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveadmission to a skilled nursing facility (SNF).You asked the Planto pre-approvethe admission. You say that this is medically necessary.The Plandenied your request. The Plansaysthis 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 the admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing 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 skilled nursing facility setting.We looked atthis physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the admission have not been met.Therefore, we decided that the Plandoes not haveto pre-approveadmission to a skilled nursing facility (SNF).
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 cannot walk or talk and the transfer to the LTACH facility was recommended. The Plan denied your request. The Plan says the enrollee is receiving appropriate care in the current facility.
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 acute care hospital (ACH) following a stroke. The enrollee was intubated/ventilated and subsequently received a tracheotomy. The enrollee is no longer on a ventilator. 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 long term care 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve gastric bypass reversal.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied
your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that
the services are not medically necessary. Our physician reviewer found the enrollee had a gastric bypass in
2009 complicated by severe reactive hypoglycemia for four years. Gastric bypass reversal can be necessary to
treat refractory reactive hypoglycemia; however, there are medical and dietary treatments that should be
considered. The enrollee completed dietary and endocrine evaluations without significant success. There is no
documentation of failure of medical efforts with acarbose or octreotide. All non-surgical treatment should be
exhausted prior to surgery. The reversal is 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 gastric bypass reversal.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvedental crown (D2740), root canal (D3320), endodontic procedure (D3999), prefabricated post and core (D2954), limited oral evaluation (D0140), core buildup (D2950), crown lengthening (D4249), gingival irrigation (D4921), incomplete endodontic therapy (D3332), and treatment of root canal (D3331).You asked the Plan to pre-approvedental services. You say that you have been struggling with your teeth for over a year and need these services.The Plan denied your request. The Plan says thedenial of authorization for these services is correct, because these dental services are not covered by your Plan's dental benefits.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.The Plan already approved one crown and one root canal procedure, therefore additional crowns and root canals would not be covered. Therefore, we decided that the Plan does not have to pre-approvedental crown (D2740), root canal (D3320), endodontic procedure (D3999), prefabricated post and core (D2954), limited oral evaluation (D0140), core buildup (D2950), crown lengthening (D4249), gingival irrigation (D4921), incomplete endodontic therapy (D3332), and treatment of root canal (D3331)
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay formolecular genetic screening testing (CPT Code(s): 87491, 87591) provided on September 15, 2020.You asked the Plan to pay forthe testing. You say that the testing is necessary.The Plan denied your request. The Plan says these services are not authorized because molecular genetic screening testing is not a Medicare benefit for the diagnoses as listed on the claim and are done for screening purposes.The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.The test at issue in this appeal, the testing, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes.Therefore, we decided that the Plan does not have to pay formolecular genetic screening testing (CPT Code(s): 87491, 87591) provided on September 15, 2020
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approvea pontic (D6240) for tooth #14 and retainercrowns (D6750) for tooth #'s 13 and 15.You asked the Plan to pre-approvethe pontic and retainer crowns. You say that you were told you need a new bridge to connect the three teeth or you will lose all three.The Plan denied your request. The Plan says that these services are not medically necessary.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 Plancovers the pontic and retainer crowns 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 pontic and retainer crowns. Our reviewer says that the pontic and retainer crowns are medically reasonable and necessary. Our physician reviewer found there is a presence of a defective fixed bridge replacing tooth #14 using #'s 13and 15 as abutment retainers. Recurrent caries associated with the #13 abutment retainer requires removal of the bridge. Our reviewer found that new crowns are required to restore teeth #'s 13 and 15 to proper function. Our physician reviewer also found that it is medically reasonable to place a new fixed bridge to replace missing tooth #14 since the abutment teeth #'s 13 and 15 require crown restorations.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 pontic and retainer crowns have been met.Therefore, we decided that the Plan has to pre-approvea pontic (D6240) for tooth #14 and retainer crowns (D6750) for tooth #'s 13 and 15.If the Plandoes 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 doesnot 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 are appealing with supporting records.The Plan denied your request. The Plan says the denial of authorization for IRF service is correct.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 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. While the record documents a need for physical and occupational therapy, it does not document a need for an intensiverehabilitation program. There is not a reasonable expectation that the enrollee 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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveMirena IUD.You asked the Plan to pre-approveMirena intrauterine device (IUD). You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested item is not a covered benefit.The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill.In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be brought to the office for administration. Since the medication does not represent an expense to the physician and will not be included in the physician's bill, it is not eligible for Part B coverage.Therefore, we decided that the Plan does not have to pre-approveMirena IUD.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on September 25, 2020, by an OON provider.You asked the Plan to pay foran X-ray of the knee. You say that this service was medically necessary.The Plan denied your request. The Plan says rules for payment have not been met.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to 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 forthe medical services provided on September 25, 2020, by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the crown, 3/4 porcelain, (D2783) provided on August 21, 2020.

You asked the Plan to reimburse you for the dental service. You say that the Plan advised your dental office that the crown would be covered at $861. You say that you paid for the service out of pocket because the Plan did not pay for it. You also say that you are on a fixed income and would be grateful if the plan reimbursed you for the service. The Plan denied your request. The Plan says the crown, 3/4 porcelain, is not listed as a covered service. The Plan also says that any services not listed are not covered.

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. The Evidence of Coverage clearly states that any services not listed are not covered. Therefore, we decided that the Plan does not have to reimburse you for the crown, 3/4 porcelain, (D2783) provided on August 21, 2020.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approvea chemotherapy regimen of Gemzar, oxaliplatin, and Rituxan.You asked the Plan to pre-approvechemotherapy drugs. You say that you are appealing with supporting records.The Plan denied your request. The Plan says that the denial of authorization for these drugs is correct, because this combination is not supported by the National Comprehensive Cancer Network.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 chemotherapy drugs. Our reviewer says that the enrollee meets the Medicare criteria for use of the requested drug combination. Our physician reviewer found although this combination is not supported by major drug compendia, its use is supported by clinical research in a Medicare-approved medical journal which allows first line use in the elderly.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of chemotherapydrugs have been met.Therefore, we decided that the Plan has to pre-approvea chemotherapy regimen of Gemzar, oxaliplatin, and Rituxan.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 toopen the case again, we will send you a letter
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approveAranesp (J0881).You asked the Plan to pre-approveAranesp. You say that the service is medically necessary.The Plan denied your request. The Plan says the enrollee has not met the step therapy requirements.Medicare covers Part B medications when they are reasonable and necessary but allows health plans toimplement 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 Aranesp. Our reviewer says that the service is not medically necessary. Our physician reviewer found that the enrollee has not tried and failed the required step therapy drug and there is no documentation provided indicating that the Plan's required drug would likely be less effective and/or likely have adverse effects 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 Aranesp have not been met. Specifically, the enrollee has not met the step therapy requirements. This means the service is not medically necessary or reasonable.Therefore, we decided that the Plan does not have to pre-approveAranesp (J0881).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forhospital discharge management services (99239) provided on February 26, 2019.You asked the Plan to pay forhospital discharge management services. You say that the claim was untimely because you depend on the providing facility for timely notification of the enrollee's insurance benefits.The Plan denied your request. The Plan says rules for payment have not been met.The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service.The record shows that a claim for hospital discharge management services was not filed until August 7, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed.Therefore, we decided that the Plan does not have to pay forhospital discharge management services (99239) provided on February 26, 2019