Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve proton beam therapy.
You asked the Plan to pre-approve the requested services. You say that proton therapy improves overall
survival and reduces high grade complications for head and neck cancers. The Plan denied your request. The
Plan says proton therapy would not provide a clinically meaningful benefit over a well-designed intensitymodulated
radiation therapy (IMRT) plan.
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 requested services. Our physician
reviewer found that proton therapy is not an accepted standard of care for routine practice for typical locally
advanced head and neck cancers. For patients with bulky cancers, bulky nodal disease or contralateral nodal
disease, it is often challenging to meet parotid constraints, or maintain acceptable target coverage while also
maintaining acceptable cord and larynx constraints. However, these situations do not apply for this enrollee.
There is nothing in the case records, and there is no appeal letter, describing why this enrollee's case might be
exceptional and therefore require proton therapy. Based upon the provided records, it is not plausible that
proton therapy would provide a clinically meaningful benefit over a well-designed IMRT plan. Therefore,
while not experimental, its potential benefit over non-proton based radiation is investigational. Thus, proton
therapy is not necessary as it would not be furnished in accordance with accepted standards 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 the requested services have not been met. Therefore, we decided that the Plan
does not have to pre-approve proton beam therapy.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the colonoscopy provided on February 4, 2020.
You asked the Plan to waive the copayment for the colonoscopy. You say that this should be fully covered because you were getting a screening colonoscopy and then did a sigmoidoscopy to remove polyps. 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 $225 copayment for each outpatient surgery and/or service at an ambulatory surgical center or outpatient hospital facility. You have been asked to pay a $225 copayment for the colonoscopy. The colonoscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The record shows polyps were removed which makes the service diagnostic in nature.
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 colonoscopy provided on February 4, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approveendodontic therapy on a molar tooth (D3330).You asked the Plan to pre-approveendodontic therapy on a molar tooth. You say that you need this because you are in pain.The Plan denied your request. The Plan says this service is not covered.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approveendodontic therapy on a molar tooth (D3330).
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 IRF services are medically necessary . The Plan denied your request. The Plan says the enrollee does not meet Medicare criteria for coverage.
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 an alternative 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forERCP provided on January 10, 2020.You asked the Plan to waive the copayment forERCP. You say that you feel that the charges should be included in the first surgical procedure.The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $350 copayment for surgery services provided in an outpatient hospital facility. You have been asked to pay a $350 copayment for ERCP. ERCP 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 nothave to waive the copayment forERCP provided on January 10, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says that there are no
noted daily skilled nursing or therapy needs which can only be provided on an inpatient basis.
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 services. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found that your condition does not meet
Medicare criteria for SNF services.
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 services have not been met. Therefore, we decided that the Plan does not
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Methotrexate for the enrollee.
You asked the Plan to pre-approve this drug. The Plan denied your request. The Plan says that this is not
covered under Part B.
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 Methotrexate for the
enrollee.
Benefits for this drug 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 Plandoes not have to pre-approve intermittent limb compression device with code E0652.You asked the Plan to pre-approveintermittent limb compression device. You say that this device is medically necessary, and only this device can provide the therapy ordered by the provider.The Plan denied your request. The Plan says the denial of authorization for this device is correct, because no measurements of the legs over a period of several weeks were provided, all prescriptions attempted and failed were not described, the enrollee states walking and sitting most of the day without leg elevation, and no description of ulcer was noted along with the wound consultation report.The Plan follows Medicare rules. The rules state that Medicare covers pneumaticcompression devices coded as E0652 when the enrollee meets certain criteria and has failed a four-week trial with a pneumatic compression device coded as E0650 or E0651.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 intermittent limb compression device. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested pneumatic compression device. Ourphysician reviewer found the records do not show completion and failure of a four-week trial of conservative therapy with a basic pneumatic compression device (E0650 or E0651) to justify this request.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of intermittent limb compression device have not been met.Therefore, we decided that the Plan does not have to pre-approveintermittent limb compression device with code E0652
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient hospital care.
You asked the Plan to pre-approve acute inpatient hospital care. You say that given your medical history,
inpatient admission is appropriate. The Plan denied your request. The Plan says the denial of authorization for
acute inpatient hospital care is correct.
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 the record does not show that at the time of inpatient admission, the
admitting physician reasonably expected that your necessary hospital care (including earlier emergency
department or observation 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 care.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay fora diagnostic mammogram (77065) provided February 28, 2020.You asked the Plan to pay for the mammogram. You say that the service was medically necessary.The Plan denied your request. The Plan says the claim submitted is a duplicate.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.We find that CPT code 77065 is not supported in the medical record. Specifically, the claim as filed is a duplicate of a claim already processed. Based on this information, we decided that Medicare rules for coverage of the mammogram have not been met.Therefore, we decided that the Plan does not have to pay fora diagnostic mammogram (77065) provided February 28, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH)
for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan
denied your request. The Plan says the request was denied because the information provided did not show the
criteria was not 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 the enrollee is currently undergoing treatment at an ACH following a cardiac arrest.
The enrollee was intubated/ventilated and found to have a prolonged QT interval. The enrollee subsequently
developed bacteremia and infectious diarrhea. The enrollee eventually received a tracheotomy. The enrollee
appears to still be on a ventilator with no clear documentation of attempted weaning. There is no evidence that
the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide
the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can
remain at the current ACH until such time no acute services are required. The enrollee can then be
transferred/discharged to a lower level of care for any ongoing long term care needs.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve fluoride carriers.You asked the Plan to pre-approve fluoride carriers. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested services are not a covered 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 fluoride carriers.
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. The Plan denied your request. The Plan says the enrollee does not require complex wound management.
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 physician reviewer found that the enrollee is currently undergoing treatment at an acute care hospital (ACH) for a sacral decubitus. The enrollee is not intubated/ventilated. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) coverage after June 3, 2020.You asked the Plan to pre-approve continued SNF coverage. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested services are not medically necessary.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 continued SNF coverage. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral medications. The enrollee had stable vital signs. The enrollee required moderate to maximum assistance/dependent assistance with functional mobility including walking to 10 feet. The documentation does not support that the enrollee requires the specialized skills, knowledge, or judgment of a skilled professional nurse or qualified therapist to safely and effectively provide medically necessary and reasonable treatment. The documentation does not support that skilled nursing or skilled therapy services are required on a daily basis. As a practical matter, the enrollee does not require the necessary services on an inpatient basis, at a SNF 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 continued SNF coverage have not been met.Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) coverage after June 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on January 21, 2020 by an out of
network (OON) provider.
You asked the Plan to pay for physician services. You say that you would like this appeal reprocessed and
approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained.
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 physician services provided on January 21, 2020
by an out of network (OON) provider.
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 the SNF admission. You say that you feel that daily therapy would be helpful for you.The Plan denied your request. The Plan says there is no need for daily skilled care. Your needs are mostly custodial at this time.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 the SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the beneficiary is a 73 year old female with COPD, recent covid-19 pneumonia with hospitalization and CHF admitted to the hospital with UTI, acute kidney injury and pneumonia. From a nursing perspective, the beneficiary received oral and inhaled medications. The beneficiary had stable vital signs. She was treated for a pneumonia. Regarding rehabilitation services, the beneficiary received PT and OT in the acute hospital. The beneficiary was at a stand by assist t to contact guard assist level with functional mobility including gait to a few feet. The beneficiary required varying assist with ADLS.There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. This beneficiary 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 the SNF admission 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: Unfavorable

We decided that the Plan does not have to pay for skilled nursing services provided on November 8, 2019 by an out of network (OON) provider.
You asked the Plan to pay for skilled nursing services. You say that you would like this claim reprocessed and approved for payment. You say that it is the facility's responsibility to get prior authorization. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that the referring facility is also out-of-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 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 skilled nursing services provided on November 8, 2019 by an out of network (OON) provider.