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

We decided that the Plan does not have to pre-approve routine transportation trips.
You asked the Plan to pre-approve routine transportation trips. You say that you are beginning radiation treatment. The Plan denied your request. The Plan says routine transportation is not approved. The Plan states routine transportation is not covered by your benefit plan.
The Plan must follow Medicare rules. Medicare does not cover transport in a vehicle that is not an ambulance. The Plan follows the same rule. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Medicare rules for coverage of routine transportation trips have not been met. Therefore, we decided that the Plan does not have to pre-approve routine transportation trips.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the positron emission tomography (PET) skull to mid-thigh (78815).
You asked the Plan to pre-approve the PET scan. You say that the medical records provided will show proof of medical necessity. The Plan denied your request. The Plan says the medical records received do not support the medical necessity and the enrollee does not have the covered indication for the procedure.
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the PET scan. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee does not meet Medicare criteria for PET scan at this time. She has not had a workup of her chest adenopathy other than the order for a PET scan. The medical records do not indicate any signs or symptoms of a tumor at this time. 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 PET scan have not been met. Therefore, we decided that the Plan does not have to pre-approve the positron emission tomography (PET) skull to mid-thigh (78815).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the services are 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 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 care. Our reviewer says that daily
skilled services are not necessary. Our physician reviewer found the enrollee does not have documented skilled
nursing needs. The enrollee does not have documented skilled therapy needs. Daily skilled services are not
required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The
enrollee's care needs at this point are custodial and, as a practical matter, can be provided 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 SNF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the telephone evaluation and management service (99442) provided on November 27, 2020.

You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says that this service is not payable as the claim was improperly billed.

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. Specifically, the Plan's decision is based on the submitted claim being billed with an inappropriate address for a location of services. The Plan has not forwarded a claim to verify the address that was used. Additionally, the Place of Service code billed is appropriate for telehealth services. It is the burden of the Health Plan to substantiate their denial with evidence. The Plan has not provided evidence in this case; therefore, we must find in your favor. Therefore, we decided that the Plan has to pay for the telephone evaluation and management service (99442) provided on November 27, 2020.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve submucosal ablation of the tongue base (41530).

You asked the Plan to pre-approve the submucosal ablation of the tongue base. You say that you would like reconsideration because the member is unable to do other treatments and declines Uvulopalatopharyngoplasty; a dental device as well as a continuous positive airway pressure device. The Plan denied your request. The Plan says that this is a non-covered service per Medicare.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the submucosal ablation of the tongue base. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found submucosal radiofrequency tongue base ablation can be a viable, safe treatment option for adults suffering from mild to moderate obstructive sleep apnea (OSA). The enrollee has a moderate level of OSA and it is untreated. The member is unable to do other treatments and declines Uvulopalatopharyngoplasty; a dental device as well as a continuous positive airway pressure device.

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 submucosal ablation of the tongue base have been met. Therefore, we decided that the Plan has to pre-approve submucosal ablation of the tongue base (41530).

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 four surgical placements of implant bodies: endosteal implants (D6010 x4), four prefabricated abutments (D6056 x4), and four implant supported crowns (D6066 x4).
You asked the Plan to pre-approve the endosteal implants, prefabricated abutments, and implant supported crowns. You say that you need these services 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 four surgical placements of implant bodies: endosteal implants (D6010 x4), four prefabricated abutments (D6056 x4), and four implant supported crowns (D6066 x4).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Linx knee (L5828, L5845, L5848, L5856, L5973) for the enrollee.

You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the request for a microprocessor knee and foot exceeds the member's need and does not meet the Medicare criteria of reasonable and 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 requested items/services are not considered medically reasonable and necessary in this case. Records indicate the enrollee requires a rolling walker for ambulation which is not consistent with a K3 ambulator. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for these services.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a Linx knee (L5828, L5845, L5848, L5856, L5973) for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for
the enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your
request. The Plan says there is no need for this 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 complexity of the enrollee's nursing, medical and rehabilitation needs does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee
was admitted for hip revision surgery with acute blood loss anemia. Medical problems are stable. There are no
complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies,
including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program.
While the medical record supports a need for physical and/or occupational therapy, there is no documented
need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care.
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-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a LTACH for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan
denied your request. The Plan says the enrollee is receiving appropriate inpatient acute care and does not
require transfer to the LTACH.
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 there is no documentation provided necessitating admission to a LTACH. The
enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at
the LTACH that are not available at the acute care hospital where she is currently receiving care. 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 health plan. 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 admission to a LTACH for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a non-invasive ventilator.

You asked the Plan to pre-approve a non-invasive ventilator. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested device is not medically necessary.

The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. 

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 non-invasive ventilator. Our reviewer says that the requested ventilator is not medically necessary. Our physician reviewer found the enrollee has immunodeficiency, bronchiectasis, and chronic obstructive pulmonary disease (COPD), although there is no confirmation with pulmonary function tests. There is no documentation of hypercapnia. Medicare does not cover a home ventilator when used as bilevel positive airway pressure (BiPAP). There is no evidence of BiPAP failure. Therefore, the enrollee does not meet criteria for the requested device. 

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 non-invasive ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a non-invasive ventilator.
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 these services are medically necessary. The Plan denied your request. The Plan says that the enrollee's therapy needs are not complex enough to require 3 hours of therapy/day from multiple disciplines.

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. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for a stroke and were transferred to skilled nursing on April 9, 2021. Your medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cardiology services to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve OON services. You say that in-network physicians do not have expertise in your condition. The Plan denied your request. The Plan says there are network cardiologists that can treat your condition.

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 OON services. Therefore, we decided that the Plan does not have to pre-approve cardiology services to be provided by an out of network (OON) provider.
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 admission. You say that this is medically necessary. The Plan denied your request. The Plan says there is no need for daily skilled services on an inpatient 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 the admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found while you may be expected to benefit from skilled therapy services, the documentation does not support that you require skilled therapy on a daily basis in an inpatient SNF setting. No required skilled nursing services are identified. Skilled services are not needed on a daily 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 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home ventilator (E0466).

You asked the Plan to pre-approve a home ventilator. You say that this device is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says this home ventilator is not medically necessary.

The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD.

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 home ventilator. Our reviewer says that the requested ventilator is not medically necessary and reasonable. Our physician reviewer found the enrollee is a 76-year-old female with a past medical history of chronic obstructive pulmonary disease and respiratory failure. Based on the medical records provided, there is documentation that this patient has chronic respiratory failure consequent to chronic obstructive pulmonary disease. However, there is no documentation that the ventilator at issue is medically necessary and reasonable for this patient as the records do not show that the patient has failed a Bilevel Positive Airway Pressure (BiPAP) device (E0471) with Average volume-assured pressure support (AVAPS) capability.

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 home ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a home ventilator (E0466).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Enhertu.

You asked the Plan to pre-approve Enhertu. You say that the services are 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 Enhertu. Our reviewer says that the medication is not medically necessary. Our physician reviewer found Enhertu (Fam-trastuzumab deruxtecan) is not FDA approved for the treatment of head and neck or salivary gland tumors. Use is not supported by the medical literature or the major drug compendia. The service 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 Enhertu have not been met. Therefore, we decided that the Plan does not have to pre-approve Enhertu.