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

We decided that the Plan does not have to pre-approve the insertion of a Vertiflex Superion Interspinous device (22869).

You asked the Plan to pre-approve the insertion of a Vertiflex Superion Interspinous device. You say that this is medically necessary. The Plan denied your request. The Plan says this is experimental.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the insertion of a Vertiflex Superion Interspinous device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the spacer device is experimental. More research is needed to show safety and efficacy. 

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 insertion of a Vertiflex Superion Interspinous device have not been met. Therefore, we decided that the Plan does not have to pre-approve the insertion of a Vertiflex Superion Interspinous device (22869).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the acute inpatient hospital care.

You asked the Plan to pre-approve acute inpatient hospital care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
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 documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found there is no clinical rationale for the requested inpatient admission. The enrollee is medically stable. The planned procedure is listed under CPT codes 23472 is not listed on the CMS Inpatient Only List. The procedure is currently approved as an ambulatory procedure. There is no documentation provided to support the expectation the enrollee will require a greater than 2 midnight stay. If the member experiences any peri- or post-operative complications, reconsideration for inpatient level of care can be performed. The review has determined that the record does not show that inpatient admission is 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 acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pre-approve the acute inpatient hospital care.
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 services are necessary. The Plan
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

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 there are no services at the LTACH that the enrollee requires that are not already
available and covered at the current facility. Therefore, this request for LTACH will be considered not
medically necessary at this time. Transfer may be considered when treatment has completed.

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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.

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 enrollee does not meet criteria for IRF admission. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for rib fractures, ventricular tachycardia, and COVID 19 pneumonia. Medical conditions are stable. There are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. 

The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, in an intensive rehabilitation therapy program. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation 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.
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 would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested admission is 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 requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found you were admitted for cholecystitis, sepsis and pulmonary embolism. Your medical conditions are stable. The documentation does not support that you require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 

The documentation does not support that you require an intensive rehabilitation therapy program. The enrollee's care needs can be met at a lower level of care. 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips for the 2021
calendar year.

You asked the Plan to pre-approve the additional trips. You say that you have many scheduled appointments
and will run out of rides unless the Plan allows you to have more. The Plan denied your request. The Plan says
your routine transport benefit only covers 24 trips per year. This benefit cannot be extended.

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 a maximum of 24 trips per year.

We looked at your request, the records in the case file, and the rules. Based on this information, we decided
that you will exhaust the Plan maximum benefit for coverage of routine transportation after the 24th trip.
Although you may require more trips, there is no provision in the contract which would obligate the Plan to
extend this benefit. Therefore, we decided that the Plan does not have to pre-approve additional routine
transportation trips for the 2021 calendar year.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99213) provided on June 8, 2020.

You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says your out-of-network benefit has been exhausted; therefore, the service is not payable.

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 for services received out-of-network (POS), enrollees pay a 30% coinsurance. The Plan will reimburse a maximum of $3,000 for out-of-network (POS) services per calendar year. You have been asked to pay the billed amount of $121 for the office visit rendered by an out-of-network provider. The Plan out-of-network (POS) benefit allows for reimbursement in the amount of $3,000 per calendar year. The Plan previously issued payment in the amount of $3,000 for services rendered in the 2020 calendar year; therefore, the benefit has been exhausted. 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 pay for the office visit (99213) provided on June 8, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home ventilator.

You asked the Plan to pre-approve a home ventilator. You say that the requested home ventilator is medically
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for a home
ventilator.

The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory
failure due to COPD.

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 home ventilator. Our reviewer says
that the enrollee does not meet criteria for a home ventilator. Our physician reviewer found the enrollee is with
a history of chronic obstructive pulmonary disease (COPD), Chronic Respiratory Failure, obstructive sleep
apnea, congestive heart failure (CHF), diabetes mellitus and obesity. The member was hospitalized for hypercapnic respiratory failure and was prescribed a Trilogy machine at that time. He was hospitalized again for COPD exacerbation and decompensated CHF. His current medications include Breo Ellipta, Combivent Respimat, Ipratropium-Albuterol, and Pro-Air HFA. The case file indicates that he was previously effectively treated with CPAP/BiPAP and wishes to return to that modality due to the cost of the trilogy ventilator. The request is for continued rental of Trilogy machine.

At issue s whether the trilogy ventilator is a covered service. The record indicates that the enrollee can be
treated with CPAP/BiPAP. Therefore, the trilogy ventilator cannot be recommended.

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 home ventilator have not been met. Therefore, we decided that the Plan does
not have to pre-approve a home ventilator.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

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 enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at a lower level of care. 

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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a consultation (D9310) and extraction of teeth #14 and 15 (D7210) to be performed by an oral surgeon.

You asked the Plan to pre-approve a consultation and extraction of teeth #14 and 15 to be performed by an oral surgeon. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

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. The Plan states that covered services must be performed by a participating general dentist. 

We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a consultation and extraction of teeth #14 and 15 to be performed by an oral surgeon have not been met. Therefore, we decided that the Plan does not have to pre-approve a consultation (D9310) and extraction of teeth #14 and 15 (D7210) to be performed by an oral surgeon.
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 enrollee would benefit from care in
the LTACH setting. The Plan denied your request. The Plan says there is no clinical advantage to transfer to an
LTACH over remaining in the current facility.

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 patient is a 41-year-old female who was admitted to the current acute care
hospital with metabolic acidosis, hyperkalemia, respiratory failure, and acute kidney injury requiring
intubation, tracheostomy, hemodialysis. The course was complicated by cardiac arrest likely due to blood clots
in the lungs which were treated. Pneumonia and deep vein clots were also diagnosed and treated.

The patient appears to be still requiring acute care services over the short-term due to active treatment needs
which can safely be administered at the current facility until able to discharge to a lower level of care. The
patient does not require services at the LTACH that are not already available at the current facility. Therefore,
this request for LTACH will be considered not medically necessary at this time. Transfer may be considered
when treatment has completed.

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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Humira.

You asked the Plan to pre-approve Humira. You say that the enrollee has tried and failed Methotrexate and Enbrel. The Plan denied your request. The Plan says the requested drug is not covered under the 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 Humira.

Benefits for Humira 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 incontinence supplies.

You asked the Plan to pay for incontinence supplies. You say that with your doctor's prescription this has been covered. The Plan denied your request. The Plan says this item is not a covered benefit.

The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable.

While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pay for incontinence supplies.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Carboplatin.

You asked the Plan to pre-approve Carboplatin. You say that the records provided support the medical necessity of the requested drug. The Plan denied your request. The Plan says the enrollee does not meet the clinical criteria for coverage.

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. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the requested drug is only FDA-approved for metastatic disease and is not recommended to be used in combination with other drugs. The use of the requested drug is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal for a T1c and node negative patient. 

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 have not been met. Therefore, we decided that the Plan does not have to pre-approve Carboplatin.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a rheumatology office visit provided on October 7, 2020.

You asked the Plan to waive the copayment for specialist visit. You say that this is your primary care physician and is not a specialist. The Plan denied your request. The Plan says the copayment amount you are being charged is correct.

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 copayment for each in-network specialist visit. This provider is a rheumatology specialist; therefore, the specialist copayment applies to this claim. 

You have been asked to pay $40 copayment for specialist visit. Specialist visit falls within the Physician/Practitioner Services, Including Doctor's Office Visits benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a rheumatology office visit provided on October 7, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650).

You asked the Plan to pay for the lumbar-sacral orthosis. You say that the service was medically necessary. The Plan denied your request. The Plan says the records do not support the enrollee ever having an examination with the provider.

The Plan follows Medicare rules. Medicare rules say that criteria listed in LCD L33790 must be met for this service to be 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 lumbar-sacral orthosis. Our reviewer says that the service does not meet Medicare criteria Our physician reviewer found the available documentation in the case file does not support that the requested lumbar-sacral orthosis was medically reasonable and necessary for the enrollee in this case, according to the coverage criteria established by the LCD. An appropriate history and a physical examination of the back would reasonably be required to adequately assess whether the coverage criteria for an LSO have been met. The documentation does not support that the lumbar-sacral orthosis was prescribed for one or more of the covered indications in this case, as there is insufficient documentation of a credible physical examination of the back. 

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 lumbar-sacral orthosis have not been met. Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650).