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 you disagree with the denial. The Plan denied your request. The Plan says the services are 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 services are not medically necessary. Our physician reviewer found the enrollee is currently undergoing treatment at an ACH following a scheduled appendectomy, complicated by perforation, abscess and adhesions. 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. The enrollee can remain at the current ACH until such time no acute services are required. 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a fully-electric hospital bed for the enrollee.You asked the Plan to pre-approve the bed. You say that this is medically necessary.The Plan denied your request. The Plan says this is not a covered benefit, as the electric height adjustment feature is considered a convenience option.The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered. While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers coverage for this item.Therefore, we decided that the Plan does not have to pre-approve a fully-electric hospital bed for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of sodium ferric gluconate complex.You asked the Plan to pre-approve sodium ferric gluconate. You say that you need these infusions due to your iron being low.The Plan denied your request. The Plan says the denial of authorization for these drugs is correct.The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 sodium ferric gluconate. Our reviewer says that you do not meet the Medicare criteria for use of the requested sodium ferric gluconate. Our physician reviewer found the documentation does not clearly establish a diagnosis of iron deficiency, an inability to take oral nutrition and medications, or a failure of oral nutrition and medications. The documentation is insufficient to establish that the use of intravenous iron is medically reasonable or necessary for you.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of sodium ferric gluconate have not been met.Therefore, we decided that the Plan does not have to pre-approveuse of sodium ferric gluconate complex.
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 IRF care is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet the medical criteria for coverage of IRF 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 the medical records show that the complexity of the enrollee's nursing, medical, and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does require skilled physical therapy and occupational therapy, but does not require treatment in an intensive rehabilitation therapy program. There is concern that the enrollee would not be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Care at the skilled nursing facility level with physical and occupational therapy appears to be indicated 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 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda 25mg/ml IV solution for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says the Medicare requirements for Keytruda require a positive genetic testing result for EGFR and ALK mutations.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found the review relates to a request for Keytruda to treat metastatic non-small cell lung cancer (NSCLC) in the enrollee who received Carboplatin/Alimta/Keytruda in 2019 and has been on maintenance Alimta. Provider testing of the peripheral blood found no mutations of EGFR, ALK, ROS1, RET, BRAF or MET. The submitted documents state the enrollee has been on maintenance Alimta from 10/19 to 3/16. The last imaging included in the documentation is a CT scan dated 3/12/20 showed shrinkage of the lung mass and persistence of involved nodes and right pleural effusion with small new left pleural effusion. In the past, the right pleural effusion was negative for tumor cells. There is no indication if the new effusion has been tested. There is no indication in the submitted documentation that the enrollee has progression of the cancer. While Keytruda is supported for use as continuation maintenance treatment when the drug is used in first line combination treatment, the requested use is not for continuation as he has been off the drug since 10/2019. There is insufficient information in the submitted documentation to indicate that the drug is medically reasonable and necessary or that it is safe and effective for the enrollee. 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 drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Keytruda 25mg/ml IV solution for the enrollee.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approveTecentriq.You asked the Plan to pre-approvethese services. You say that you disagree with the denial.The Plan denied your request. The Plan says that the services are not medically necessary.The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 enrollee has prostate cancer with progression to metastatic diagnosis in October of 2019. The biopsy is consistent with a small cell cancer. These cancers are treated the same as extensive stage small cell lung cancer with carboplatin/etoposide with Tecentriq. The Tecentriq is reasonable and medically 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 these services have been met.Therefore, we decided that the Plan has to pre-approveTecentriq.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee would be equally well served at an alternate level of care, such as discharge to home with home health services, and family assistance as needed.
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 admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. The 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 the admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for SNF care provided to the enrollee from December 23, 2019 through January 21, 2020.You asked the Plan to pay for SNF care. You say that the stay was medically necessary.The Plan denied your request. The Plan says the stay is 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 topay for SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The beneficiary does not require skilled nursing or therapy services on a daily basis. 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 SNF care have not been met.Therefore, we decided that the Plan does not have to pay for SNF care provided to the enrollee from December 23, 2019 through January 21, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says needs can be met safely in a skilled nursing facility setting.
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 records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a SNF level of care. Ongoing pain medication and other medication management, wound care, and daily therapy can be provided at a SNF. A less intensive, longer duration of therapy will allow for measurable gains to be attained within a reasonable period. 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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a tooth extraction and related treatments.
You asked the Plan to pre-approve the dental services. You say that you would like these services performed and covered. The Plan denied your request. The Plan says these services are not a covered benefit, and tooth #3 was previously extracted on June 20, 2018.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. The majority of the services at issue in this case are not covered. Additionally, each tooth is only allowed to be extracted once per lifetime, and tooth #3 was already extracted on June 20, 2018. Therefore, we decided that the Plan does not have to pre-approve a tooth extraction and related treatments.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on December 11, 2019.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 testing is not covered.The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes.Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on December 11, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the cost-sharing for anesthesia services provided on January 15, 2020.You asked the Plan to waive the cost-sharing for anesthesia. You say that in the previous year you only paid $45 copayment for these services.The Plan denied your request. The Plan says that the cost-sharing amount you are being charged is correct.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 rules say a Plan must disclose to its enrollees in clear and accurate terms all cost-sharing information. Your contract with the Plan says that enrollees must pay $45 copayment for each in-person specialist office visit, including medical care and surgery services.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 did not provide documentation showing that these anesthesia services were part of a distinct in-person specialist office visit from the other specialist services you are being charged cost-sharing for on date of service January 15, 2020. The Plan did not provide documentation showing the place of service for these services to justify a cost-sharing amount other than the specialist visit copayment. Without this information, we cannot determine that separate cost-sharing applies to this claim beyond the cost-sharing amount you have already been charged. The total cost-sharing amount you have been asked to pay for this claim and other specialist professional or surgical services on date of service January 15, 2020 is $226.19.For the specific claim at issue in this case you have been asked to pay $29.89. Therefore, even by fully waiving the cost-sharing for this claim, the cost-sharing amount you are being asked to pay remains in excess of the $45 specialist copayment for these services. Therefore, we decided that the Plan has to waive the cost-sharing for anesthesia services provided on January 15, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvehome health speech therapy for the enrollee.You asked the Planto pre-approvethe services. You say that this is medically necessary.The Plandenied your request. The Plansaysthe request is not medically necessary, because the records do not document that the physician ordered these additional services.The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.We asked our physician reviewer to carefully review the case fileand apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found the enrollee is apparently not home-confined and/or unable to address ongoing language and cognitive needs via outpatient therapy. Therefore, this request is not medically 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 services have not been met.Therefore, we decided that the Plandoes not haveto pre-approvehome health speech therapy for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveadmission to a long term acute care hospital (LTACH) for the enrollee.You asked the Planto pre-approvethe LTACH services. You say that this is medically necessary.The Plandenied your request. The Plansaysthe enrollee's chronic conditions are stable.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 for shortness of breath, attributed to pneumonia and fluid overload. The enrollee was transiently intubated/ventilated, but is no longer 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. 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 Plandoes not haveto pre-approveadmission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Keytruda (J9271) and Abraxane (J9264).
You asked the Plan to pre-approve Keytruda and Abraxane. You say that this is medically necessary. The Plan denied your request. The Plan says that the enrollee has tried this regimen and it wasn't effective.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 Keytruda and Abraxane. Our reviewer says that the requested drugs are supported in this case. Our physician reviewer found this enrollee has disease progression on pembrolizumab for metastatic non-small cell lung cancer. It is an acceptable standard of care to add chemotherapy to immunotherapy for progression with a single agent in patients that have received prior platinum therapy. As it is greater than 6 months since the enrollee has received abraxane, this is an acceptable option. The service is reasonable and medically 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 Keytruda and Abraxane have been met. Therefore, we decided that the Plan has to pre-approve Keytruda (J9271) and Abraxane (J9264).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe outpatient hospital services rendered on December 23, 2019.You asked the Plan to waive the copayment forthese services. You say that you shouldn't have to pay for the procedure.The Plan denied your request. The Plan says the copayment was applied correctly.Therules 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 $150 copayment for Medicare-covered outpatient surgery in an ambulatory surgical center or hospital outpatient facility. Review of the file shows that you received outpatient surgical services at an outpatient hospital facility on December 23, 2019. You have been asked to pay a $150 copayment for these services. These services fall within the Medicare-covered outpatient surgery in an ambulatory surgical center or hospital outpatient facility 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 forthe outpatient hospital services rendered on December 23, 2019.