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

We decided that the Plan does not have to pay for the skilled nursing services provided from July 9, 2019 to July 23, 2019.
You asked the Plan to pay for the skilled nursing services. You say that the services that the enrollee required and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee did not have skilled nursing or skilled rehabilitation needs nor did he receive skilled therapy only available at a SNF.
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 pay for the skilled nursing services. 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. Based on this information, we decided that Medicare rules for coverage of the skilled nursing services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided from July 9, 2019 to July 23, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an inpatient hospital admission for surgery services.
You asked the Plan to pre-approve an inpatient admission. The Plan denied your request. The Plan says the
procedure can be performed on an outpatient basis.
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 pre-approve an inpatient admission. Our physician
reviewer found that you have a peripheral neuropathy. Surgical decompression of the sciatic nerve, with
possible sural nerve graft, and decompression of the right common peroneal nerve is planned. There is no
documentation of any complicating factors. The record does not show that your necessary care will span two
midnights. It is not medically reasonable and necessary for you to receive inpatient hospital services for the
procedure. The planned surgery can safely be performed in the outpatient setting, with a conversion to inpatient
admission if there are complications of the procedure that require additional medically necessary care that
would extend the time in the hospital to greater than 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 an inpatient admission have not been met. Therefore, we decided that the Plan
does not have to pre-approve an inpatient hospital admission for surgery services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Brovana (Arformoterol).
You asked the Plan to pre-approve Brovana. The Plan denied your request. The Plan says the enrollee has not met step therapy requirements.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Brovana. Our reviewer says that Brovana is not medically reasonable and necessary. Our physician reviewer found that the enrollee is noted to have COPD. A request has been made for Brovana, to treat the COPD. The health plan requires that Performist be tried first. There is no evidence that the enrollee is allergic to or intolerant of Performist. There is no evidence that the enrollee has tried and not responded to Performist. There is no documentation as to why Performist would not be expected to be safe and effective for the enrollee. Therefore, the requested Brovana is not shown to be currently medically necessary and reasonable. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Brovana have not been met. Therefore, we decided that the Plan does not have to pre-approve Brovana (Arformoterol).
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve combination therapy with atezolizumab (Tecentriq) and bevacizumab-awwb (Mvasi).
You asked the Plan to pre-approve the Tecentriq/Mvasi therapy. You say that this is a necessary treatment for this enrollee's condition. The Plan denied your request. The Plan says that the compendia do not support this regimen for 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 the Tecentriq/Mvasi therapy. Our reviewer says that the requested chemotherapy regimen is considered medically reasonable and necessary. Our physician reviewer found the enrollee has a history of hepatocellular carcinoma due to non-alcoholic Steatohepatitis (NASH) which was diagnosed in 2018. The cancer is unresectable and has had no prior first line treatments. This regimen is not FDA-approved for this condition; however, there is support for this treatment from a study published in the Annals of Oncology, "Randomised efficacy and safety results for Atezolizumab (Atezo)+ bevacizumab (Bev) in patients (PTS) with previously untreated, unresectable hepatocellular carcinoma (HCC)". Based on this support, the reviewer has indicated that treatment is 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 the Tecentriq/Mvasi therapy have been met. Therefore, we decided that the Plan has to pre-approve combination therapy with atezolizumab (Tecentriq) and bevacizumab-awwb (Mvasi).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Freestyle Lite diabetic test strips.
You asked the Plan to pre-approve the Freestyle Lite brand strips. You say that the enrollee needs this specific brand. The Plan denied your request. The Plan says there is no documentation that the non-preferred brand is medically necessary.
The Plan must follow Medicare rules. Medicare rules say that plans may restrict enrollees to certain brands for medical equipment/supplies as long as all medically necessary brands are accessible. In this case, there is no documentation provided that the non-preferred brand is medically necessary or that the preferred brands would be medically inappropriate. You have been approved for a 90-day supply of the non-preferred brand to ease the transition to the preferred brand. Without documentation of the reason the non-preferred brand is medically necessary, the rules for coverage of the requested brand have not been met. Therefore, we decided that the Plan does not have to pre-approve Freestyle Lite diabetic test strips.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital services provided August 1 to August 5, 2019.
You asked the Plan to pay for the inpatient services. You say that services were medically necessary. The Plan denied your request. The Plan says the services at issue were not authorized and out-of-network.
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, approval is required. 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 inpatient services. Our reviewer says that the services at issue do not meet coverage criteria. Our physician reviewer found the enrollee was hemodynamically stable and appropriate for ambulance transport with monitoring to a Plan facility after the emergency room evaluation. 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 inpatient services have not been met. Therefore, we decided that the Plan does not have to pay for inpatient hospital services provided August 1 to August 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical or manipulative therapy (S8990) provided on October 2, 2019 and October 9, 2019.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial as the chiropractic care received was very helpful in relieving the chronic pain you had been experiencing. The Plan denied your request. The Plan says chiropractic maintenance therapy is not a covered benefit by Medicare or your health plan.
The Plan must follow Medicare rules. The rules say that Medicare does not cover chiropractic maintenance care. We looked at the case file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Specifically, chiropractic maintenance care is a non-covered benefit by Medicare. Therefore, we decided that the Plan does not have to pay for the physical or manipulative therapy (S8990) provided on October 2, 2019 and October 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nurse practitioner services provided on August 14, 2019.
You asked the Plan to pay for the nurse practitioner services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 did not pre-approve the service at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for nurse practitioner services provided on August 14, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a second opinion evaluation for repetitive transcranial magnetic stimulation (rTMS) treatment (90868).
You asked the Plan to pre-approve a second opinion evaluation for rTMS treatment. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been met. Therefore, coverage criteria has not been met.
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 a second opinion evaluation for rTMS treatment. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found utilizing the information from this enrollee, it indicates this enrollee does not have an indication for the requested Repetitive Transcranial Magnetic Stimulation (rTMS). Based on the records provided, the enrollee does not meet the criteria or treatment with Repetitive Transcranial Magnetic (rTMS). 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 second opinion evaluation for rTMS treatment have not been met. Therefore, we decided that the Plan does not have to pre-approve a second opinion evaluation for repetitive transcranial magnetic stimulation (rTMS) treatment (90868).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to adjust the reimbursement for the power lift chair purchased on August 29, 2019.
You asked the Plan to adjust the reimbursement for the power lift chair. You say that the approved reimbursement was nowhere near the price of the power lift reclining chair. The Plan denied your request. The Plan says you were reimbursed 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 40% coinsurance for durable medical equipment and related supplies. You have been asked to pay 40% coinsurance for the power lift chair. The power lift chair falls within the durable medical equipment and related 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. Medicare does not reimburse sales tax separately. Medicare does not cover the upholstered portion of a seat lift recliner. The Plan has reimbursed you the Medicare allowable rate, for the seat lift mechanism portion, minus your out-of-network coinsurance. Therefore, we decided that the Plan does not have to adjust the reimbursement for the power lift chair purchased on August 29, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for medical nutrition therapy services (97803) provided September 16, 2019.
You asked the Plan to pay for medical nutrition therapy services. You say that your PCP thought it was important that you consult with a nutritionist given your personal and family history of heart disease, high blood pressure and high cholesterol. The Plan denied your request. The Plan says the enrollee's diagnosis of hyperlipidemia does not meet the criteria.
The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services only for enrollees with renal disease or diabetes. Records do not show that you suffer from renal disease or diabetes. Therefore, we decided that the Plan does not have to pay for medical nutrition therapy services (97803) provided September 16, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for chronic care management services provided on September 30, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the chronic care management services. You say that there is a medical necessity pre-established with the enrollee and the facility to provide services to the enrollee's needing care. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider. The plan says that non-emergent services with non-contracted providers require prior-authorization prior to services being rendered.
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 has network providers available who can provide 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 chronic care management services provided on September 30, 2019 by an out of network (OON) provider.
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 IRF care is medically necessary. The Plan denied
your request. The Plan says the enrollee does not meet criteria for coverage of IRF 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 above.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found the complexity of the patient's nursing, medical, and rehabilitation needs do not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The
documentation does not reveal that the patient's medical status requires the intensity of an IRF stay with close
physician or nursing supervision. The patient may benefit and participate in additional physical and
occupational therapy; however, she does not require this on an intensive rehabilitation facility therapy program
level 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 an acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for foot orthotics.
You asked the Plan to pay for foot orthotics. You say that the Health Plan told you there is coverage for orthopedic shoes. 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 pay for foot orthotics.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Retacrit (Q5106).
You asked the Plan to pre-approve Retacrit. You say that the medication is necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that ESAs are covered when specific criteria is met. 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 Retacrit. Our reviewer says that the service is not medically necessary. Our physician reviewer found the enrollee has a diagnosis of iron deficiency anemia and is currently being treated with intravenous iron. Creatinine is 1.53; there is no diagnosis of advanced chronic kidney disease. The documentation does not support that the Retacrit is medically reasonable and necessary for the enrollee. The documentation does not support that the Retacrit is 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 Retacrit have not been met. Therefore, we decided that the Plan does not have to pre-approve Retacrit (Q5106).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a botox injection to the pylorus.
You asked the Plan to pre-approve a botox injection to the pylorus. You say that the requested botox injection is medically necessary. The Plan denied your request. The Plan says the requested botox injection is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a botox injection to the pylorus. Our reviewer says that the requested botox injection is not medically necessary. Our physician reviewer found the enrollee is with diagnoses of Gastroparesis, Gastro-esophageal reflux disease without esophagitis, and Mixed irritable bowel syndrome. She has had a paraesophageal hernia repair in the past. Upper endoscopy on 2/26/19 demonstrated a medium amount of food (residue) in the stomach. A capsule exam on 5/14/15 was normal. Causality between pyloric dysfunction and symptoms of gastroparesis has not been adequately demonstrated. Although several open-label studies showed initial promise, 2 randomized clinical trials have failed to demonstrate a difference in clinical outcomes between botulinum toxin and placebo in the treatment of gastroparesis. 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 botox injection to the pylorus have not been met. Therefore, we decided that the Plan does not have to pre-approve a botox injection to the pylorus.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the nasal endoscopy provided on October 22, 2019.
You asked the Plan to waive the copayment for the nasal endoscopy. You say that you cannot afford this and you were not aware that there was going to be a charge. 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 $250 copayment for Medicare-covered outpatient surgery in an ambulatory surgical center or hospital outpatient facility. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the $250 copayment for the nasal endoscopy.
You have been asked to pay a $198.85 copayment for the nasal endoscopy. The nasal endoscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" 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 nasal endoscopy provided on October 22, 2019.