Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea power wheelchair and related accessories.You asked the Plan to pre-approvethe requested items. The Plan denied your request. The Plan says durable medical equipmentmust be for use in the residence other than a health care institution.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home. The records show that the requested items are being requested for use in a SNF. Medicare does not consider a SNF to be a home. Therefore, we decided that the Plan does not have to pre-approvea power wheelchair and related accessories.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ZILRETTA.
You asked the Plan to pre-approve these services. You say that the services are medically necessary. 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 previously been treated with various medications for knee osteoarthritis. Previous treatment with ZILRETTA is stated to have afforded the most improvement in symptoms. There is no support in the Medicare-approved compendia for the repeated use of ZILRETTA to treat osteoarthritis. The ZILRETTA is not considered safe and effective 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 ZILRETTA.
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 this is medically necessary. The Plan denied your request. The Plan says you not have daily skilled needs.
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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not have identifiable skilled nursing or therapy needs and do not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis, complete series of intraoral x-rays, and bitewings provided on October 28, 2019.
You asked the Plan to pay for the prophylaxis, complete series of intraoral x-rays, and bitewings. You say that you are a new enrollee and enrolled in this plan to continue dental benefits and assure continuity of care with your dentist. You also say that according to the documentation, you are entitled to two routine dental cleanings per year. The Plan denied your request. The Plan says this provider does not participate in your Plan's dental network. The Plan also says that services done by an out-of-network dentist 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 covered when they are received out-of-network. Therefore, we decided that the Plan does not have to pay for the prophylaxis, complete series of intraoral x-rays, and bitewings provided on October 28, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (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 there is no clinical advantage of LTACH over the acute hospital.
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 is currently undergoing treatment at an ACH for a NSTEMI and rhabdomyolysis. 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 admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (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 having low blood pressure, and has not been on the ventilator long enough to become stable on it.
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 long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not provide clinical services that are materially different than those of short term acute care hospitals. In this case, ongoing care needs include respiratory support with oxygen supplementation, ventilator management and weaning, wound care, intravenous antibiotics, surveillance laboratory studies, tube feedings, skin care, and therapy services. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the fecal blood test provided on March 16, 2020.
You asked the Plan to waive the copayment for the fecal blood test. You say that you thought all preventive care was covered. 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 $10 per day, per provider, for in-network, Medicare-covered lab services. You have been asked to pay a $10 copayment for the fecal blood test. The fecal blood test falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the fecal blood test provided on March 16, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a chemotherapy regimen of carboplatin and docetaxel.
You asked the Plan to pre-approve carboplatin and docetaxel. You say that you are appealing with records. The Plan denied your request. The Plan says the denial of authorization for these drugs is correct, because these drugs are only used in specific clinical situations which do not include the enrollee's condition.
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 carboplatin and docetaxel. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested carboplatin and docetaxel. Our physician reviewer found the same guidelines for adjuvant systemic therapy in women with early-stage breast cancer are generally followed for men who have breast cancer. The proposed regimen of carboplatin and docetaxel is used for triple negative breast cancer. This enrollee has hormone positive breast cancer. The requested service is therefore not medically reasonable or 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 carboplatin and docetaxel have not been met. Therefore, we decided that the Plan does not have to pre-approve a chemotherapy regimen of carboplatin and docetaxel.
Appeal type: Home Health
Decision: Favorable

We decided that the Plan has to pre-approve continued home health services.
You asked the Plan to pre-approve the home health services. You say that you would like reconsideration because without these services, you are unable to leave your home. The Plan denied your request. The Plan says that the provider has not submitted any documentation to substantiate the request for continued home health services.
The Plan must follow Medicare Rules. The rules say that Medicare plans must tell an enrollee that the Plan will stop paying for home health services. The Plan must issue a NOMNC no later than two days before the last covered day. This notice must include a description of the enrollee's right to an appeal. We looked at the file and the Medicare rules. The file does not show that a valid NOMNC was delivered two or more days before April 11, 2020. Specifically, the NOMNC in the record does not include a signature. Additionally, the record indicates that the rendering provider is in-network. A contract provider is an agent of the Plan and medical records are considered to be within the Plan's control. In this case, the documentation submitted does not include and medical records to review for the medical necessity of continued home health services. Therefore, we decided that the Plan has to pre-approve continued home health services.
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: Favorable

We decided that the Plan has to pay for the periodic oral evaluation, bitewings, and prophylaxis provided on June 25, 2019.
You asked the Plan to pay for the periodic oral evaluation, bitewings, and prophylaxis. You say that according to your 2019 Evidence of Coverage booklet, both in-network and out-of-network services should be a $0 copay. The Plan denied your request. The Plan says that the Plan's normal allowable on the charges submitted was $104.00, but since the Dental plan paid $115.00, they exceeded the Plan's normal benefit, had the Plan been the primary carrier.
Medicare rules provide specific directions on when secondary payment may be made and how to calculate said payment. While Medicare does not cover dental services, your plan does provide supplemental coverage which in this case is secondary to a primary dental plan. Medicare rules say that secondary payment is made, up to the maximum amount payable, for any amount that the provider is legally allowed to collect from the enrollee after primary payment has been made. The contract rules indicate that the provider is allowed to bill the enrollee any amount greater than the payment made by the plan.
In this case, the Plan has made zero payment and states that the MAC for this service is $104. Neither Medicare rules nor the language of the contract allow the plan to deny payment based on any amount paid by a primary payer. Based on the documentation from the primary payer's Explanation of Benefits, the provider may collect up to $115 for costs not covered by the primary plan. As the MAC for these services on your secondary dental plan is less than the amount billable by the provider, your Plan must make secondary payment in the amount of $104 for the periodic oral evaluation, bitewings, and prophylaxis provided on June 25, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the core build up (D2950) and root canal (D3330) provided on October 11, 2019.
You asked the Plan to pay for the dental services. You say that you have gone to this provider before. You also say that the provider advised these services would be covered before she did anything. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan also says that dental services received out of network 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 dental services you received are not covered when you receive them out of network. Therefore, we decided that the Plan does not have to pay for the core build up (D2950) and root canal (D3330) provided on October 11, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve simvastatin tablets.
You asked the Plan to pre-approve self-administered drugs. You say that you are appealing. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because this drug is not covered by Medicare Part B and the Plan does not administer the enrollee's Medicare Part D prescription drug benefits.
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 simvastatin tablets.
Benefits for self-administered drugs 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for knee orthosis (L1851), wrist hand orthosis (L3916) and suspension sleeve (L2397) provided to the enrollee on December 9, 2019.
You asked the Plan to pay for the orthoses and sleeve. You say that the durable medical equipment is medically necessary. The Plan denied your request. The Plan says they were unable to discover any evidence of an established relationship between the member and the ordering physician. The Plan states there were no claims submitted for an evaluation and management service. The Plan states the review of claims history for this member, and a review of the submitted documentation does not contain evidence of a prior Telemedicine or Telehealth service with the ordering physician as required per CMS guidelines.
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 orthoses and sleeve. Our reviewer says that the enrollee does not meet criteria for the orthoses and sleeve ordered. Our physician reviewer found the documentation in the case file does not support that the requested knee orthosis and sleeve were medically reasonable and necessary for the enrollee in this case, according to the coverage criteria established by the LCD.
There is no credible documentation of a recent injury to, or recent surgical procedure on, the enrollee's knee, and there is insufficient credible objective documentation of joint laxity. The item coded L2397 (sleeve) is not separately payable when the base item is not covered. 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 orthoses and sleeve have not been met. Therefore, we decided that the Plan does not have to pay for knee orthosis (L1851), wrist hand orthosis (L3916) and suspension sleeve (L2397) provided to the enrollee on December 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the physician's services.You asked the Plan to pre-approve the physician's services. You say that you have been under the care of this physician since being diagnosed with pancreatic cancer in 2015. You say that you have developed and excellent rapport and trust with this physician. You say that continued office visits for treatment with this physician are necessary to your health and your life. The Plan denied your request. The Plan says coverage for out-of-network providers is allowed only when the service is medically necessary but unavailable within the network or when an emergency. As this is not the case there is no medical necessity for coverage with an out-of-network provider at the present time.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve the physician's services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for secondary diagnosis of J96.01, Acute Respiratory Failure from September 19, 2018 through September 22, 2018.
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your request. The Plan says the services are medically necessary.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG. 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 physician reviewer found the review has determined that the records did not support that the secondary diagnosis of J96.01, Acute Respiratory Failure was appropriate for the hospital stay. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate DRG J96.01. Therefore, we decided that the Plan does not have to pay for secondary diagnosis of J96.01, Acute Respiratory Failure from September 19, 2018 through September 22, 2018.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the enrollee needs a hospital level of care for rehab with close medical management and nursing oversight. The Plan denied your request. The Plan says the enrollee does not have complex medical management needs, and does not require supervision by a rehab physician.
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 physician reviewer found that the enrollee is at minimal assistance for bed mobility and transfers. She is at supervision for basic activities of daily living, and moderate assistance for bathing. The records note that the acute metabolic encephalopathy has resolved, and CT scan of the head was negative. 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. Her current medical status does not require intensive physician or nursing oversight in an IRF. The enrollee may benefit from additional multiple therapies, however her functional level, which is appears near baseline, does not require that this therapy must be in an IRF with an intensive level program. 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.