Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that the IRF admission is medically necessary. The Plan denied your request. The Plan says the enrollee's needs can be met at a different level of care.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's needs can be met at an alternate 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 IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional eight (8) hours of Private Duty Nursing services (CPT code(s) S9124 and S9123).

You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your request. The Plan says the services are not covered.

The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. The health plan must follow CMS rules and guidance per the Medicare Benefit Policy Manual Chapter, the services of a private duty nurse or other private duty attendant are not covered. Furthermore, the submitted codes for service, S9124 and S9123 are status I codes which are not valid codes for Medicare services. Medicare uses another code for reporting of, and payment for, these services. Therefore, we decided that the Plan does not have to pre-approve additional eight (8) hours of Private Duty Nursing services (CPT code(s) S9124 and S9123).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that this can help to relieve the ongoing pain. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that an IRF admission is medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of an IRF admission.
The Plan must follow Medicare rules. The rules say that an IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at a lower level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied
your request. The Plan says the services are not medically necessary.

The Plan must follow Medicare rules. The rules say that 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 these services. Our reviewer says that
the services are not medically necessary. Our physician reviewer found the enrollee has large cell
undifferentiated lung and neck metastases. Keytruda is indicated for head and neck cancer as first-line
treatment (in combination with platinum and fluorouracil) of metastatic or unresectable recurrent head and
neck squamous cell carcinoma (HNSCC), first-line, single-agent treatment of metastatic or unresectable
recurrent HNSCC in patients whose tumors express PD-L1 (CPS =1), as determined by an approved test, and
as a single-agent treatment of recurrent or metastatic HNSCC in patients with disease progression on or after
platinum-containing chemotherapy. The enrollee does not satisfy any of these criteria; therefore, Keytruda is
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 Keytruda.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xeljanz XR 11mg ER tablets.

You asked the Plan to pre-approve Xeljanz. You say that this medication is medically necessary. The Plan denied your request. The Plan says Xeljanz is not eligible for coverage under the Part B medical benefit.

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 Xeljanz XR 11mg ER tablets.

Benefits for Xeljanz may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete denture.
You asked the Plan to pre-approve the dentures. You say that this is medically necessary. The Plan denied your
request. The Plan says the benefit has been exhausted.
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 dentures once
every five years.
Dentures were last received less than five years ago on October 8, 2019. Based on this information, we decided
that the Plan's rules for coverage of the dentures have not been met. Therefore, we decided that the Plan does
not have to pre-approve a complete denture.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for ankle-foot orthotics (AFO) with ankle joint (L1971) and foot plastic heel stabilizer (L3170) provided on October 6, 2020.
You asked the Plan to pay for AFO and foot plastic heel stabilizer. You say that the items are medically necessary. The Plan denied your request. The Plan says there was insufficient documentation submitted.
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 AFO and foot plastic heel stabilizer. Our reviewer says that the requested items are not considered medically reasonable and necessary in this case. Our physician reviewer found a physical examination of the ankles and feet would reasonably be required to adequately assess whether the coverage criteria were met. The documentation does not support that the orthoses were medically reasonable and necessary in this case, as there is insufficient documentation of a credible evaluation with a credible physical examination of the ankles and feet. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of AFO and foot plastic heel stabilizer have not been met. Specifically, there is insufficient documentation to establish medical necessity of the requested items. Therefore, we decided that the Plan does not have to pay for ankle-foot orthotics (AFO) with ankle joint (L1971) and foot plastic heel stabilizer (L3170) provided on October 6, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing facility services (99307, 99309) provided March 1, 2020 to June 1, 2020.
You asked the Plan to pay for the skilled nursing facility services. You say that the services should be reimbursed. The Plan denied your request. The Plan says the enrollee's skilled nursing facility was exhausted at the time the services were provided.
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care. The file shows that the enrollee received 100 days of SNF care during the benefit period from March 1, 2020 to June 1, 2020 . The Plan has covered 100 days of SNF care. Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF coverage during this benefit period. The enrollee will be eligible for a new benefit period when the enrollee has not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided that the Plan does not have to pay for skilled nursing facility services (99307, 99309) provided March 1, 2020 to June 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services and orthotic (97763, 99213) provided
from August 20, 2020, to September 10, 2020, by an OON provider.
You asked the Plan to pay for the dental services. You say that you believed this care was covered. The Plan
denied your request. The Plan says they do not cover out of network services except in limited circumstances.
The Plan did not pre-approve these services, nor were they urgent. The Plan had in-network providers who
would have been able to provide this care with a prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan had network providers
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for the dental services and orthotic (97763, 99213)
provided from August 20, 2020, to September 10, 2020, by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a filling (D2391) for tooth # 29 and a root canal (D3310) for tooth # 8.
You asked the Plan to pre-approve the dental services. You say that the services are necessary. The Plan denied your request. The Plan says tooth # 29 has previously been extracted. The Plan says that fillings are not covered for teeth that have been extracted. The Plan also says that root canal is not a covered service.
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 and fillings are a covered service, fillings are not covered for teeth that have previously been extracted. Additionally, root canal is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a filling (D2391) for tooth # 29 and a root canal (D3310) for tooth # 8.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a removable unilateral partial denture (D5282).
You asked the Plan to pre-approve the dental item. You say that you have dentures currently. You also say that they are old and not very efficient. The Plan denied your request. The Plan says removable unilateral partial denture is not listed as a covered dental item.
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 removable unilateral partial denture is not among those covered under this benefit. The Customer Handbook clearly states that if a dental item or service is not listed in the benefit chart then it is not covered. Therefore, we decided that the Plan does not have to pre-approve a removable unilateral partial denture (D5282).
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for radiology services (70486, 70450, 71045) provided on April 27, 2020.
You asked the Plan to pay for radiology services. You say that these services are supported in the records. The Plan denied your request. The Plan says that additional documentation is needed to add this provider under the group's Tax Identification Number.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan has stated that these services were denied because additional information was needed, but they have not provided details of what information was needed and what Medicare criteria have not been met by the information provided. Therefore, we decided that the Plan has to pay for radiology services (70486, 70450, 71045) provided on April 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for prolonged evaluation and management services (CPT 99358) provided to the enrollee on September 22, 2020 and September 23, 2020.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says it does not appear appropriate to use the CPT code 99358 when it is not related to a face-to-face service, either before or after the date the prolonged service is performed.
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 99358 is "Prolonged evaluation and management service before and/or after direct patient care; first hour." 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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our physician reviewer found the medical records provided do not include documentation to confirm there was a face-to-face encounter with the patient either before or after billing 99358 on 9/22/2020 and 9/23/2020, therefore it is inappropriate to bill this code for the services performed.
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 services have not been met. Therefore, we decided that the Plan does not have to pay for prolonged evaluation and management services (CPT 99358) provided to the enrollee on September 22, 2020 and September 23, 2020.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve magnetic resonance imaging (MRI) of the lumbar spine (72148).

You asked the Plan to pre-approve this service. You say that an MRI of the lumbar spine is medically necessary for the enrollee. The Plan denied your request. The Plan says this service is 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 this service. Our reviewer says that an MRI of the lumbar spine is medically necessary. Our physician reviewer found that the use of magnetic resonance imaging should be reserved for selected patients, such as the following: An immediate MRI of the spine is indicated in patients with progressive neurologic deficits or cauda equina syndrome, patients with a presentation that is suggestive of malignancy, patients with a known history or high risk of malignancy, or in cases in which there is a clinical suspicion to evaluate for a possible inflammatory disease or infection. MRIs are not necessary in all patients who have examination findings that are consistent with a radiculopathy; in fact, these studies should generally be reserved for those cases in which the imaging results are likely to guide treatment. In this case the enrollee has radiculopathy ongoing despite conservative therapy. Therefore, the requested MRI study is medically reasonable and 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 this service have been met. Therefore, we decided that the Plan has to pre-approve magnetic resonance imaging (MRI) of the lumbar spine (72148).

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-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee exceeds the Centers for Medicare & Medicaid Services (CMS) criteria for a LTACH appropriate admission. The Plan denied your request. The Plan says this request is not medically necessary.
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 enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. Our reviewer found that there are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the Plan. Our physician reviewer also found that the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 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 LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the mandibular partial denture (D5214).
You asked the Plan to pre-approve the mandibular partial denture. You say that this service is necessary for your condition. The Plan denied your request. The Plan says this is not a covered service under your 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 pre-approve the mandibular partial denture (D5214).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve electromagnetic treatment to be provided by an out of network provider.
You asked the Plan to pre-approve electromagnetic treatment. You say that multiple standard therapies have not been successful. You say that the enrollee needs five treatments to make the pain go away. The Plan denied your request. The Plan says the Plan cannot approve services from an out of network providers.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve electromagnetic treatment to be provided by an out of network provider.