Persius/hicric huggingface dataset:
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 the enrollee was admitted to the acute care hospital on 4/30/21 with respiratory failure due to COVID-19 pneumonia with Acute respiratory distress syndrome (ARDS). A tracheostomy and a PEG tube have been placed. The enrollee has generalized deconditioning. On 6/8/21, the enrollee was tolerating a trach collar. 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. The enrollee is receiving acute hospital care, and acute care services have not been denied. 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 she is currently receiving care. The documentation does not support that an additional 25 days of hospitalization are reasonably expected for the enrollee in this case. 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 long term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Favorable

We decided that the Planhasto pay forthe stereotactic computer-assisted craniectomy for excision of a brain tumor with microsurgical techniques billed with codes 61518, 61781, and 69990.You asked the Planto pay forthe brain tumor excision procedure. You say that these services were correctly reported with diagnosis code C79.31. There is no reason this code cannot be used.The Plandenied your request. The Plansaysthatpayment is not allowed for this service because it is not appropriate for the diagnosis billed. A corrected claim must be submitted with an appropriate diagnosis code.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 failed to provide any citation to a coding rule or regulation to supports its determination that diagnosis code C79.31 is not appropriate for billing with these services. The diagnosis code is defined as Secondary malignant neoplasm of brain. These codes describe excision of a brain tumor, also known as a neoplasm. This diagnosis code clearly matches the reported diagnosis in the records which was treated with the services described by the billed codes. We find this denial of payment is not substantiated.Therefore, we decided that the Planhas to pay forthe stereotactic computer-assisted craniectomy for excision of a brain tumor with microsurgical techniques billed with codes 61518, 61781, and 69990.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xtampza Er capsules.
You asked the Plan to pre-approve Xtampza Er capsules. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says Xtampza Er 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 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 Xtampza Er capsules.
Benefits for Xtampza Er 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 an initial consultation with an out of network (OON) provider.

You asked the Plan to pre-approve the initial consultation with an OON provider. You say that the requested OON provider is one of the best specialists in the enrollee's diagnosis and is globally recognized. You say that the enrollee's condition is serious and that the requested OON provider has agreed to treat the enrollee. The Plan denied your request. The Plan says there are available providers in the network that can supply the care needed by the enrollee.

Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan providers available to meet the enrollees' needs. The enrollee's contract with the Plan says that, with few exceptions, enrollees must use contract providers for care.

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 initial consultation with an OON provider. Our reviewer says that the criteria for coverage of OON care have not been met. Our physician reviewer found the Plan's denial is medically justified on the basis that it is offering adequate care to meet the enrollee's medical needs through referral to an in-network provider. Our physician reviewer found that there is nothing unique about the enrollee's condition that would make it medically necessary for him to see the requested OON provider. The Plan has shown that they have in network providers who meet the Standards of Care required for treatment of the enrollee's condition.

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 initial consultation with an OON provider have not been met. Therefore, we decided that the Plan does not have to pre-approve an initial consultation with an out of network (OON).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda.
You asked the Plan to pre-approve Keytruda. You say that this drug is medically necessary. The Plan denied
your request. The Plan says the requested drug is not medically necessary 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 Keytruda. Our reviewer says that the
requested drug is not medically necessary and reasonable. Our physician reviewer found the enrollee is a 58-
year-old with gastric cancer. In this case, the cited study is for esophageal and gastroesophageal (GE) junction
and as 1st line therapy. This patient has gastric cancer. In addition, this patient has completed chemotherapy
and per study would be given with chemotherapy. The use of Keytruda to treat the enrollee's condition is not
supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical
journal.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have
to pre-approve Keytruda.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.You asked the Plan to pre-approve a shower chair. You say that this is necessary because you live alone.The Plan denied your request. The Plan says this item is not a covered benefit.The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item.Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay forthe home health services rendered from November 30, 2020 to December 1, 2020.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the claims were billed incorrectly.The Plan must follow Medicare rules. The rules say that the Type of Bill (TOB) code 032x is required for home health services under a plan of treatment.We looked at the file and Medicare rules. The file shows that the claims were not billed with the required 032x TOB code. 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 pay forthe home health services rendered from November 30, 2020 to December 1, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy to be provided by the requested out-of-network provider.You asked the Plan to pre-approve the physical therapy. You say that these therapists will provide for the necessary continuity of care for your chronic knee issue.The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the Plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the Plan.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 physical therapy to be provided by the requested out-of-network provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for Skilled Nursing Facility services provided September 4, 2019 to October 3, 2019.
You asked the Plan to pay for the Skilled Nursing Facility services. You say that the services were medically necessary. The Plan denied your request. The Plan says coverage criteria was not met.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the Skilled Nursing Facility services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found as a practical matter, this patient did 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 the Skilled Nursing Facility services have not been met. Therefore, we decided that the Plan does not have to pay for Skilled Nursing Facility services provided September 4, 2019 to October 3, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on January 18, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the claim was billed incorrectly.
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT codes describing the component test results. We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and
was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on January 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve neuropsychological testing (96130, 96131, 96136).You asked the Plan to pre-approve the neuropsychological testing. You say that the tests are medically necessary.The Plan denied your request. The Plan says coverage criteria has not been met.The Plan must follow Medicare rules. Medicare rules say that the patient's medical record should contain documentation that fully supports the medical necessity for testing performed.We looked at the file and Medicare rules. Only limited medical documentation was provided for review. Records were limited to a statement from the provider. Without additional clinical documentation to support the need for the tests, coverage criteria has not been met. Based on this information, we decided that Medicare rules for coverage of the neuropsychological testing have not been met.Therefore, we decided that the Plan does not have to pre-approve neuropsychological testing (96130, 96131, 96136).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Amyvid PET scan.
You asked the Plan to pre-approve this service. You say that an Amyvid PET scan is medically necessary for the enrollee. The Plan denied your request. The Plan says this service is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that there is sufficient evidence that the use of PET beta-amyloid imaging is promising to exclude Alzheimer's disease (AD) in narrowly defined and clinically difficult differential diagnoses, such as AD versus frontotemporal dementia (FTD) and to enrich clinical trials seeking better treatments or prevention strategies for AD, by allowing for a selection of patients on the basis of biological as well as clinical and epidemiological factors. 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 this service. Our reviewer says that this service is not medically necessary. Our physician reviewer found that the applicable Medical policy indicates that Amyloid PET scans are only covered as part of a clinical study that meet certain requirements. In this case the records which were provided for review did not support that the member was undergoing an Amyloid PET scan as part of a clinical study. Therefore, the requested service would not be 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 this service have not been met. Therefore, we decided that the Plan does not have to pre-approve an Amyvid PET scan.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay forphysician's services provided on October 30, 2020.You asked the Plan to pay forthe physician's services. The Plan denied your request. The Plan says Original Medicare would be responsible for paymentof all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit,through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge orrevocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated tothe terminal illness until the first day of the month following the month in which hospice was revoked or discharged. Medicare rules saythat Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal.Therefore, we decided that the Plan does not have to pay forphysician's services provided on October 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a root canal (endodontic therapy) (D3330) and treatment of a root canal obstruction (D3331).
You asked the Plan to pre-approve the endodontic services. You say that these services are necessary. The Plan denied your request. The Plan says these services are not covered by the supplemental dental benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a root canal (endodontic therapy) (D3330) and treatment of a root canal obstruction (D3331).
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 SNF. You say that the requested admission to a SNF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF admission.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve admission to a SNF. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to acute care after having a stroke with right hemiparesis and dysphagia, currently in IRF. From a nursing perspective, the enrollee received oral medications. The enrollee had stable vital signs. Regarding rehabilitation services, the enrollee received physical therapy, speech therapy and occupational therapy in the acute hospital. The enrollee was at a moderate to maximal assist level with functional mobility including gait to 40 feet in the parallel bars and was independent with wheelchair mobility. The enrollee required varying assist with activities of daily living. She tolerated a modified diet and thickened liquids. There are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. This enrollee does 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 admission to a 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional Modivcare mileage.You asked the Plan to pre-approve additional Modivcare mileage. You say that the additional transportation mileage is necessary.The Plan denied your request. The Plan says the benefit has been exhausted. Therefore, coverage criteria have not been met.Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers 36 one-way transportation trips when each one-way trip does not exceed 50 miles. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation.Therefore, we decided that the Plan does not have to pre-approve additional Modivcare mileage.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete upper denture (D5110), and a complete lower denture (D5120).
You asked the Plan to pre-approve a complete upper denture, and a complete lower denture. You say that your current dentures do not fit correctly, and you need them replaced. The Plan denied your request. The Plan says the services are a covered benefit, but you have exceeded the frequency limit of one every 5 years.
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. We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a complete upper denture, and a complete lower denture have not been met. Specifically, the record shows that you had exceeded the frequency limit on February 21, 2019. Therefore, we decided that the Plan does not have to pre-approve a complete upper denture (D5110), and a complete lower denture (D5120).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an out-of-network plastic surgery consultation.

You asked the Plan to pre-approve the consultation. You say that the cyst has grown bigger, is red, itchy and it is bothering you. You say that it is causing you pain and you are concerned that it is getting bigger. The Plan denied your request. The Plan says the services 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 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. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve an out-of-network plastic surgery consultation.