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

We decided that the Plan has to pre-approve the hearing aids.
You asked the Plan to pre-approve the hearing aids. You say that there was an authorization for treatment approved in February but it was cancelled because the enrollee wished to change primary care providers. You are uncertain why the new request was denied. The Plan denied your request. The Plan says that the medical necessity criteria has not been met.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan pays for one fitting and evaluation for hearing aids every 2 years. 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 hearing aids. Our reviewer says that this enrollee meets the medical necessary criteria for hearing aid coverage. Our physician reviewer found based on the enrollee's hearing loss, he would be a good candidate for hearing aids. He has previously worn hearing aids and has had benefit from wearing them. Therefore, his level of hearing loss is aidable. It is well known that patients who suffer from hearing loss are at risk for depression, cognitive decline, and social isolation. They are also at higher risk for injury because they cannot hear their surroundings. It is always appropriate to treat a patient's hearing loss. Our only treatment option for this degree of sensorineural hearing loss is hearing aids. Therefore, the enrollee meets criteria for hearing aids. We looked at this physician's review, the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have been met. Therefore, we decided that the Plan has to pre-approve the hearing aids.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that you need therapy to regain strength. The Plan denied your request. The Plan says you do not have a need for intensive rehab, physician supervision, or a multidisciplinary team for care.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our physician reviewer found that you presented to the hospital with weakness. It was determined that your debility was from progression of your Parkinson's disease. You are able to walk with minimal assistance using a rolling walker. Your medical condition is stable. The documentation does not support that you have complex medical issues that require acute rehab nursing care, or monitoring by an inpatient rehab physician three times per week. While you may benefit from continuing physical and occupational therapy, the documentation does not support that there is need for an intensive therapy program with therapy 3 hours per day, with frequent physician oversight and an interdisciplinary approach to rehabilitation 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on September 11, 2019 by an out of network (OON) provider.
You asked the Plan to pay for lab work. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that the member's primary care physician did not refer these services.
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 lab work provided on September 11, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided on March 4, 2020.
You asked the Plan to pay for the physician services. You say that you would like the Plan to reconsider their
denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
We looked at the file and Medicare rules. Medicare payment rules say procedure codes that are incorrectly
reported with other procedure codes as a result of the misuse of the column two code with the column one code
are not payable as there are limited circumstances when the column two code may be reported on the same date
of service as the column one code. In this case, CPT code 99213 is a column two code and cannot be billed
with column one code, 20611. Based on this information, we decided that Medicare rules for coverage of the
physician services have not been met. Therefore, we decided that the Plan does not have to pay for the
physician services provided on March 4, 2020.
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 it is felt that IRF care would be best for the enrollee.
The Plan denied your request. The Plan says the enrollee does not require three hours of daily therapy.
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 is already ambulating household distances. 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: 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 admission is medically necessary. The Plan denied your request. The Plan says your needs can be met at a different level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found based on the medical records provided the complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You may require skilled physical therapy and occupational therapy but based on the medical records provided you do not require treatment in an intensive rehabilitation therapy 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient services provided on February 6, 2020.
You asked the Plan to waive the copayment for the outpatient services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says you received outpatient surgery on the date of service at issue in this appeal. The Plan says the correct copayment has applied per your contract with the Plan.
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 $300 copayment for Outpatient surgery. We looked at the file, the Plans and Medicare rules. The file shows that you have been asked to pay a $300 copayment for the outpatient services. The outpatient services falls within the Outpatient surgery benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the outpatient services provided on February 6, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Omnipods (A9274). 
 
You asked the Plan to pre-approve Omnipods. You say that the items 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. Medicare rules say that disposable drug delivery systems, including elastomeric infusion pumps (A4305, A4306, A9274) are non-covered devices because they do not meet the Medicare definition of durable medical equipment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Omnipods have not been met. Therefore, we decided that the Plan does not have to pre-approve Omnipods (A9274).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the suprascapular nerves. 
 
You asked the Plan to pre-approve the nerve RFA procedure. You say that the enrollee would benefit from this treatment for long-term pain control based on the results of the nerve block. The Plan denied your request. The Plan says there is no evidence to support this treatment for the enrollee's condition. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary.  
 
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 nerve RFA procedure. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found peripheral nerve destruction is considered medically necessary for the treatment of spasticity, severe spasmodic torticollis (cervical dystonia), and brachial plexus surgery for brachial plexus neuromas or other brachial plexus lesions. The RFA is not supported without the enrollee either having a painful condition in the neck causing the neck to move without control or needing surgery on nerves that control the movement of their neck, hands or arms. The service at issue in this case is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the nerve RFA procedure have been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the suprascapular nerves.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that an acute inpatient rehabilitation facility admission is medically necessary. The Plan denied your request. The Plan says you do not meet criteria for coverage of an IRF admission.
The Plan must follow Medicare rules. The rules say that an 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 that the complexity of your nursing, medical, and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do require physical and occupational therapy, but you do not require an intensive inpatient rehabilitation therapy program. Additionally, there is concern that you will not be able to fully participate in and benefit from an intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. Care at the skilled nursing facility level appears to be more appropriate in this case. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a positron emission tomography (PET) scan. 
 
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan denied your request. The Plan says that the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are medically necessary.  
 
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 these services. Our reviewer says that the services are medically necessary. Our physician reviewer found the enrolee has metastatic breast cancer and is on oral agents. The records do not confirm that she has had three previous PET/CT scans. The requested PET scan is reasonable and medically necessary as subsequent treatment strategy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have been met. Therefore, we decided that the Plan has to preapprove a positron emission tomography (PET) scan.  
 
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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 10 additional occupational therapy sessions.
You asked the Plan to pre-approve the 10 additional occupational therapy sessions
. You say that the documentation supports the need for the requested services. The Plan denied your request.
The Plan says the clinical documentation shows that the enrollee is completely daily activities at the previous
level and lacks details regarding the skills required for further treatment of the enrollee's condition by an
occupational therapist.
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 10 additional occupational therapy
sessions.
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 documentation does not support that
10 additional occupational therapy sessions are required to safely and effectively provide treatment that can be
safely and effectively performed only by a therapist. The documentation is insufficient to demonstrate that the
requested 10 additional occupational therapy sessions are part of a maintenance program to prevent or slow
further 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 10 additional occupational therapy sessions
have not been met. Therefore, we decided that the Plan does not have to pre-approve 10 additional
occupational therapy sessions.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xgeva (J0897). 
 
You asked the Plan to pre-approve Xgeva. You say that you would like reconsideration because the requested drug is medically necessary. The Plan denied your request. The Plan says the member does not meet step therapy exception criteria. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Xgeva. Our reviewer says that the enrollee has not trialed pamidronate or zoledronic acid Our physician reviewer found the documentation does not outline contraindications or reason this medication was not considered. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Xgeva have not been met. Therefore, we decided that the Plan does not have to pre-approve Xgeva (J0897).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve BCG in combination with interferon alfa-2b.
You asked the Plan to pre-approve the requested combination therapy. You say that this treatment should be
allowed to prevent recurrence of the enrollee's disease. The Plan denied your request. The Plan says there is no
evidence that this combination is reasonable and necessary in the peer-reviewed literature.
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 therapy. Our
reviewer says that the requested therapy is not considered medically reasonable and necessary for this enrollee's
condition. Our physician reviewer found this review relates to a request for BCG in combination with
Interferon alfa-2b to treat a woman with recurrence of high grade non-invasive bladder cancer (pTa) after
resections and BCG and Mitomycin. Per the FDA website, BCG is FDA approved for the prophylaxis of
primary or recurrent stage Ta and/or T1 papillary tumors following transurethral resection (TUR). Interferon is
not FDA approved for the bladder cancer. Interferon is not supported for monotherapy or combination therapy
for bladder cancer in any of the CMS approved compendia. This reviewer did not find any supporting citations
in a PubMed search. As such, the requested treatment regimen is not shown to 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 the requested combination therapy have not been met. Therefore, we decided
that the Plan does not have to pre-approve BCG in combination with interferon alfa-2b.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the sacroiliac (SI) joint nerves. 
 
You asked the Plan to pre-approve the RFA procedure. You say that you feel that this treatment is necessary and should be allowed. The Plan denied your request. The Plan says the literature does not support that this treatment is reasonable and necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the RFA procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee presents with chronic back and hip pain, persistent bilateral buttock pain consistent with sacro-iliitis, and inability to walk due to pain. The provider's plan includes repeat PT for home exercise, home TENS unit, medical branch block with for a sacroiliac joint radiofrequency ablation (RFA) of lateral L5, S1, S2, S3. 
 
Per a review of the peer reviewed medical literature, sacral lateral nerve branch blocks and/or ablations/neurotomies for the diagnosis and/or treatment of sacroiliac joint mediated pain are experimental and investigational. RFA for denervation, whether performed using traditional, cooled, or pulsed radiofrequency is considered experimental and therefore, not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the RFA procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the sacroiliac (SI) joint nerves.