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

We decided that the Plan does not have to pre-approve the combination of Carboplatin and Gemcitabine hydrochloride.
You asked the Plan to pre-approve the combination of Carboplatin and Gemcitabine hydrochloride. You say that the requested combination of Carboplatin and Gemcitabine hydrochloride is medically necessary. The Plan denied your request. The Plan says the requested combination of Carboplatin and Gemcitabine hydrochloride is not medically necessary.
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 the combination of Carboplatin and Gemcitabine hydrochloride. Our reviewer says that the requested combination of Carboplatin and Gemcitabine hydrochloride is not medically necessary. Our physician reviewer found the enrollee is with foot neuropathy and chronic severe hearing loss. The enrollee has cholangioca. This review relates to a request for Carboplatin to be substituted for Cisplatin in combination with Gemcitabine to treat cholangiocarcinoma for this enrollee with hearing loss and peripheral neuropathy. The use of Carboplatin is not FDA approved for use in cholangiocarcinoma. The CMS approved compendia do not support substituting Carboplatin in place of Cisplatin to treat this disease. The NCCN Guidelines Version 1.2020 Biliary Tract Cancers do not include the use of Carboplatin. Page BIL-C 2 of 3 lists the recommended treatments for unresectable/metastatic disease. Some of these regimens avoid any drugs with neuropathy or hearing loss toxicity. Therefore there are alternative regimens that would be 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 the combination of Carboplatin and Gemcitabine hydrochloride have not been met. Therefore, we decided that the Plan does not have to pre-approve the combination of Carboplatin and Gemcitabine hydrochloride.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on
October 24, 2019.
You asked the Plan to waive the copayment for the ambulance transport. You say that the provider arranged the
transport. You say that you were informed insurance would pay for the cost. The Plan denied your request. The
Plan says the copayment applied correctly.
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 $275 for
Medicare-covered ambulance services per day.
You have been asked to pay a $275 copayment for the ambulance transport. The ambulance transport falls
within the "Ambulance services" 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
the ambulance transport provided on October 24, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an MRI of the abdomen (74183).
You asked the Plan to pre-approve an MRI of the abdomen (74183). You say that the requested MRI of the
abdomen is medically necessary. The Plan denied your request. The Plan says the requested MRI of the
abdomen 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 an MRI of the abdomen (74183). Our
reviewer says that the requested MRI of the abdomen is not medically necessary. Our physician reviewer found
the enrollee is with a diagnosis of Malignant neoplasm of left kidney, nucleolar grade IV. She is status post
partial left nephrectomy on 8/14/2018. An MRI of the abdomen on 9/3/19 revealed no evidence of recurrent or
metastatic disease in the chest, abdomen, or pelvis. An unenhanced CT scan of the abdomen on 1/30/20 was
technically inadequate for the evaluation of masses.
Per NCCN Guidelines Renal Cancer 2.2020, an MRI of the abdomen is recommended within 3 - 12 months of
surgery, and then annually for 3 years or longer, as clinically indicated. A more rigorous imaging schedule or
technique modality can be considered if positive margins or adverse pathologic features (such as sarcomatoid,
high-grade (3/4), positive margins). An MRI of the abdomen is not covered at this time, as the previous MRI
was obtained less than one year ago, and the documentation does not support that an MRI more often than
annually is medically necessary for the enrollee 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 an MRI of the abdomen (74183) have not been met. Therefore, we decided that
the Plan does not have to pre-approve an MRI of the abdomen (74183).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CardioMEMs device (33289, C2624).
You asked the Plan to pre-approve the CardioMEMs device. You say that this system will help you to better monitor and manage the member's symptoms. The Plan denied your request. The Plan says the efficacy of the CardioMEMs device is uncertain.
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 CardioMEMs device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the efficacy of the CardioMEMS device is uncertain at this time and not recommended in current guidelines for the treatment of heart failure. 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 CardioMEMs device have not been met. Therefore, we decided that the Plan does not have to pre-approve a CardioMEMs device (33289, C2624).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF admission.
You asked the Plan to pre-approve the SNF admission. The Plan denied your request. The Plan says they do not see a benefit for therapy given the enrollee's advanced 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 the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. We looked at this physician's review, the file, and Medicare rules. Although the enrollee has skilled therapy needs, these needs are not on a daily basis. 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 SNF admission.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided November 25, 2019 to November 28, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that you were not feeling well and went to the emergency room and got admitted. You even cancelled a trip due to your condition. The Plan denied your request. The Plan says that the medical records do not support the medical necessity for this level of care setting.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the enrollee claims that she had been having dizziness for quite some time but since the past 2-3 weeks she had been having on and off left sided chest discomfort and numbness. The left sided numbness seemed to progress to now being associated with some slight left sided weak hand grip which prompted the ER visit. The record shows that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier ED and/or observation care) would span two midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided November 25, 2019 to November 28, 2019.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay fordrug testing services provided to the enrollee on April 12, 2019.You asked the Plan to pay forthe services. You say that this should be paid for.The Plandenied your request. The Plan says Current Procedural Terminology (CPT) code 80307 and Healthcare Common Procedure Coding System (HCPCS) code G0482 (remain not supported.The Plan must follow Medicare rules. Medicare rules say that a physician order must be present for labs to be covered. The documentation submitted did not include a physician order/lab requisition or medical records stating exactly tests were to be performed. 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 fordrug testing services provided to the enrollee on April 12, 2019.
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 the requested admission to an IRF is medically necessary.The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.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 admission to an IRF does not meet criteria. Our physician reviewer found the enrollee was admitted to acute care on 11/1/19 as trauma 1 alert after she fell out of a moving car traveling 25-30 mph, and hit her head on concrete. Per records she has been non verbal since fall. She is now extubated. She had epidural and subdural bilateral hematomas and multiple skull fractures requiring craniotomy. She had a bone cranioplasty and scalp flap advancement rotation on 2/18/20. She has PEG feedings and nebulizers. She has wound care for flap with soap and water and bacitracin daily. She is max assist x 2 witha Hoyer for bed/chair and toilet transfers. She is dependent for toileting. She is reported not safe for standing or ambulation per therapy. She is noted stable for discharge. The complexity of the enrollee's nursing, medical and rehabilitation needs donot require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's current medical status does not require intensive IRF physician or nursing supervision. The enrollee may benefit and participate from multiple therapies such as physical therapy and occupational therapy, however the documentation does not support that this enrollee requires an 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: 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 requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.
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 admission to an IRF does not meet criteria. Our physician reviewer found the enrollee presented for and is now status post spinal surgery. The complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's medical status does not require intensive IRF physician or nursing supervision. The enrollee is asymptomatic, white blood cell count trending down, and blood cultures negative. The enrollee may benefit and participate from multiple therapies such as physical therapy and occupational therapy, however the documentation does not support that this enrollee requires 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe pneumatic compression device (E0652 and E0671) to be provided by an out of network (OON) provider.You asked the Plan to pre-approvea pneumatic compression device from an OON provider. You say that you are the only provider that can help the enrollee with their Lymphademia.The Plan denied your request. The Plan says these items are available in-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 provider at issue in this case is not a network provider with the Plan. 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 pneumatic compression device from an OON provider. Our reviewer says that it is not medically necessary for these items to be provided out of network. Our physician reviewer found there is nothing unique about the enrollee's condition that would make it medically necessary for her to be seen by an out-of-network provider. An in-network provider was identified in the documentation that can meet the enrollee's 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 a pneumatic compression device from an OON provider have not been met. 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 a pneumatic compression device from an OON provider.Therefore, we decided that the Plan does not have to pre-approvethe pneumatic compression device (E0652 and E0671) 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 Linzess capsules. 
 
You asked the Plan to pre-approve Linzess capsules. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says Linzess capsules are not covered under the enrollee's Medicare Part B benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered 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 Linzess capsules.  
 
Benefits for Linzess capsules 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: 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 requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH 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 admission to a LTACH is not medically necessary. Our physician reviewer found based on the documentation provided, the enrollee is currently undergoing treatment at an acute care hospital (ACH) for congestive heart failure and chronic kidney disease. The enrollee is not intubated/ventilated. 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the cleaning and inspection of removable complete upper denture (D9932) and the cleaning and inspection of removable partial lower denture (D9935) provided on October 8, 2019. 
 
You asked the Plan to pay for the dental services. You say that the provider's office advised the services would not cost you anything and your insurance would cover it. You also say that they did not clean your dentures. You say that they had you put them on a paper towel on the counter. The Plan denied your request. The Plan says the cleaning and inspection of dentures are not covered services. 
 
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 dental services you received are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the cleaning and inspection of removable complete upper denture (D9932) and the cleaning and inspection of removable partial lower denture (D9935) provided on October 8, 2019.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to waive the copayment for the MRI provided on October 15, 2019.
You asked the Plan to reduce the copayment for the MRI. You say that you were told there would be a $50 copayment for an MRI. The Plan denied your request. The Plan says that you have been charged the correct cost sharing amount.
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 did not submit the correct Evidence of Coverage to support that the MRI has a $200 copayment. Therefore, the plan has not shown that the copayment amount you are being asked to pay is correct or justified by the health plan contract. Therefore, we decided that the Plan has to waive the copayment for a magnetic resonance imaging the MRI provided on October 15, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the on November 18, 2019.
You asked the Plan to reduce the copayment for the specialist office visit. You say that you only owe a $5
copayment because that is what your card says. You say you saw a physician's assistant and not the doctor. 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 $35
copayment per specialist visit.
You have been asked to pay a $35 copayment for the specialist office visit. The specialist office visit falls
within the "Physician/Practitioner services, including doctor's office visits" benefit category. This means that
you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan
does not have to reduce the copayment for the specialist office visit provided on November 18, 2019.