Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a maxillary partial denture (D5213).You asked the Plan to pre-approvethe maxillary partial denture. You say that your current denture does not work for breaking down your food which is causing you to only chew on the other side of your mouth. You also say that this is causing you indigestion on a daily basis and a new partial would enable you to eat properly.The Plan denied your request. The Plan says this service exceeds the maximum count allowed per period.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, maxillary partial dentures (D5213) are limited to one procedure every five plan years. The record shows that you received a maxillary partial denture (D5213) on December 13, 2016 and your partial denture benefit is now exhausted.Therefore, we decided that the Plan does not have to pre-approvea maxillary partial denture (D5213).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the CPAP device provided by an out of network provider,
You asked the Plan to pay for the CPAP device. You say that you believed you were properly informed about the requirements. The Plan denied your request. The Plan says you did not request 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 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 the CPAP device provided by an out of network provider,
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the upper partial denture (D5213) or the lower partial denture (D5214).
You asked the Plan to pre-approve the upper partial denture (D5213) and the lower partial denture (D5214). You say that the member is unable to eat due to pain and their bridge is unstable. The Plan denied your request. The Plan says these services are not covered benefits.
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 upper partial denture (D5213) and the lower partial denture (D5214) are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the upper partial denture (D5213) or the lower partial denture (D5214).
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve continued skilled nursing facility (SNF) services.You asked the Plan to pre-approveSNF services. The Plan denied your request. The Plan says that that you have reached your 100-day benefit limit.The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and ends when the enrollee has gone60 days in a row without inpatient hospital or SNF care. The file does not show that you received 100 days of SNF care during the benefit period. The Plan has only showed you have been covered for 10 days of SNF care. The Plan hasn't provided documentation confirming you were in a SNF prior to joining the Plan.Therefore, we decided that the Plan has to pre-approvecontinued skilled nursing facility (SNF) services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve surgery to the back of the mouth for the enrollee.
You asked the Plan to pre-approve the surgery. You say that this should be paid for. The Plan denied your request. The Plan says this is not covered by Medicare or the plan.
The Plan must follow Medicare rules. Medicare rules say that CPT 41530 is not a covered code. The requested surgery is coded with CPT 41530. Based on this information, we decided that Medicare rules for coverage of the surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve surgery to the back of the mouth for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean inpatient skilled nursing facility (SNF) admission.You asked the Plan to pre-approveSNF care. You say that an inpatient skilled nursing facility admission is medically necessary.The Plan denied your request. The Plan says the enrollee does not meet criteria for an inpatient skilled nursing facility admission.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 the enrollee does not meet criteria for coverage of an inpatient skilled nursing facility admission. Our physician reviewer found the enrollee does not require ongoing skilled nursing or skilled therapy services on a daily basis. Additionally, this enrollee does not require the necessary services onan inpatient basis, in a skilled nursing facility settingbeyond the last covered day. 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-approvean inpatient skilled nursing facility (SNF) admission.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve combination therapy with carboplatin, Taxol (paclitaxel), and Keytruda (pembrolizumab).
You asked the Plan to pre-approve the requested combination chemotherapy regimen. You say that it is felt that this would be helpful palliative treatment for the enrollee. The Plan denied your request. The Plan says there is no support for the use of this treatment for the enrollee.
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 requested combination chemotherapy regimen. Our reviewer says that the requested drug combination is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has a history of squamous cell carcinoma of the tongue. She underwent chemoradiation with cisplatin, then carboplatin in February 2018. She has localized recurrence for which she had surgery in March 2019. She now has new recurrence in the neck area. The use of this combination therapy is not FDA-approved for this condition. Fluorouracil is the standard of care rather than Taxol. The use of the requested regimen is not supported in the Medicare-approved drug compendia or journals. 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 requested combination chemotherapy regimen have not been met. Therefore, we decided that the Plan does not have to pre-approve combination therapy with carboplatin, Taxol (paclitaxel), and Keytruda (pembrolizumab).
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for inpatient care from November 2, 2019 to November 4, 2019.You asked the Plan to pay forinpatient care. You say that this was medically necessary.The Plan denied your request. The Plan says that the enrollee could have been treated in observation.The Plan must follow Medicare rules. Medicare rules say that PACE plans must cover all services determined necessary by the IDT to improve and maintain the enrollee's overall health status.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 inpatient care. Our reviewer says that the inpatient care at issue was medically reasonable and necessary. Our physician reviewer found the documentation does support that the requested services were services necessary and reasonable to meet the participant's needs and to improve and maintain the participant's overall health. The requested services the requested services were not experimental or cosmetic.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient care have been met.Therefore, we decided that the Plan has to pay for inpatient care from November 2, 2019 to November 4, 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: 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 admission to a skilled nursing facility (SNF). You say that the requested admission to a SNF is medically necessary.The Plan denied your request. The Plan says the requested admission to a SNF does not meet criteria.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 admission to a skilled nursing facility (SNF). Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to acute care with complaint of right thigh pain after running into a door way with his electric scooter. The enrollee underwent open reduction internal fixation on 3/18/20 for a distal femur fracture. Post operatively he was non weight bearing (NWB) on the right lower extremity.This enrollee does not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment in a SNF. The enrollee does not have a tracheostomy tube, complex wound care or other SNF level skilled nursing need. This enrollee's functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist required to safely and effectively provide medically necessary and reasonable treatment only in a SNF. The enrollee does not require these skilled nursing or skilled therapy services (or a combination of these services) on a daily basis. As a practical matter this enrollee does not require the necessary services on 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 admission to a skilled nursing facility (SNF) 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: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for intravenous infusion services provided to the enrollee on July 19, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says that the records do not support the service billed, as the submitted documentation did not contain sufficient detail to support the billed charges.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 96365 is "Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug)." 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 reviewers says that the services at issue in this case were coded correctly and supported by the medical records. Our physician reviewer found on the date of service in question, the enrollee received two IV infusions. The first infusion ran over 2hrs and 26mins. The second infusion ran over 32mins. Together, they ran for 2hrs and 58mins. Therefore, the billing of CPT 96365 and CPT 96366 x 2 is supported. While the stop time of the first infusion was not documented. The dose, concentration and infusion rates were documented. Therefore, the time of infusion was calculable. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for intravenous infusion services provided to the enrollee on July 19, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient hospital admission.
You asked the Plan to pre-approve acute inpatient hospital care. You say that the enrollee is unable to walk and cannot have physical therapy. The Plan denied your request. The Plan says the denial of authorization for inpatient hospitalization is correct, because the enrollee does not meet the Medicare criteria for inpatient status. The Plan also says that they have approved all surgical services requested, so this denial is only for 2-day inpatient hospital admission.
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 acute inpatient hospital care. Our reviewer says that the enrollee does not meet the Medicare criteria for inpatient hospital admission in this case. Our physician reviewer found there is no documentation provided necessitating a 2-day inpatient hospital stay. The requested surgical services are not listed on the Medicare inpatient-only list. Based on the clinical documentation submitted this enrollee has no significant high-risk co-morbidities. The documentation does not show that the admitting physician would reasonably expect that the enrollee's necessary hospital care would span at least 2 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 not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient hospital admission.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services provided to the enrollee on April 12, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says Healthcare Common Procedure Coding System (HCPCS) G0481 (1 unit) remains 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 for drug 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-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that you are not steady on your feet. The Plan denied your request. The Plan says the services are not medically necessary.
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 services are not medically necessary. Our physician reviewer found the records show that you were admitted to the hospital on March 12, 2020 with a change in mental status. You are now medically stable. You need supervision for transfers and bed mobility. You have no complex needs that require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You may benefit from further therapy but do not require an intensive therapy program 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a chest x-ray (CPT 71045) provided on December 6, 2019.
You asked the Plan to pay for the chest x-ray provided. You say that the enrollee had multiple exams on the date of service in dispute. You say that the reports submitted support the procedure in dispute. The Plan denied your request. The Plan says the claim in dispute is a duplicate of claim number 820193430377679 that has all the same details, and which was paid on December 11, 2019.
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. We looked at the file and Medicare rules. Review of the file shows no evidence that this claim is a duplicate. The records show that the physician provided the billed services on the date in question. The services paid under claim number 820193430377679 were provided by the physician. The Plan has not provided sufficient information to show that the claim in dispute is a duplicate of any other paid claims and they have not substantiated their denial. Therefore, we decided that the Plan does not have to pay for a chest x-ray (CPT 71045) provided on December 6, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide routine transportation.You asked the Plan to provideroutine transportation. You say that you need routinetransportation to appointments.The Plan denied your request. The Plan says you do not have a routine transportation benefit.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. The rules say that plans may offer a supplemental benefit to provide transport not covered by original Medicare. The Plan does not offer a transportation benefit. Based on this information, we decided that the Medicare rules for coverage of routine transportation have not been met.Therefore, we decided that the Plan does not have to provideroutine transportation.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a partial upper denture (D5213) and a partial lower denture (D5214).
You asked the Plan to pre-approve the dental items. You say that you need your upper and lower partial dentures to be replaced. You say that your current ones do not stay in your mouth. You also say that you are having a hard time eating. The Plan denied your request. The Plan says dentures are covered once every 5 years. The Plan says the frequency limit for dentures has been reached. The Plan also says that you last received these services on March 6, 2018.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage and dentures are a covered service, the frequency limit has been reached. Therefore, we decided that the Plan does not have to pre-approve a partial upper denture (D5213) and a partial lower denture (D5214).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy services.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the unique and sophisticated skills of a physical therapist are not required to continue to treat this condition.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 services. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the requested therapy is generally not accepted as specific and effective therapy for your condition. You have had ten prior therapy visits, and the documentation does not reveal evidence of significant objective functional improvement from this therapy. The records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or under the supervision of a therapist. You have been instructed in a home exercise program. The requested services are not part of a maintenance program, and the specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design and/or deliver a program to maintain your current condition, or to prevent and slow deterioration.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pre-approve physical therapy services.