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

We decided that the Plan has to pre-approve a thigh lipectomy.You asked the Plan to pre-approve these 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. Medicare rules say that lipectomy is covered when specific criteria are met.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 previously underwent bariatric surgery with an approximate 50 pound weight loss. She is noted to have chronic irritation of the excessive skin on the thighs from documentation dated February 20, 2020. Documentation from November 26, 2019 notes that she has some pain in her posterior legs from heaviness of the hanging skin. She has evidence of functional impairment associated with soft tissue excess of the thighs that has failed reasonable conservative management. Removal of this excess would likely resolve or significantly improve her impairment. Therefore, this should not be considered cosmetic surgery, but reconstructive surgery. The requested procedure is medically necessary 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 these services have been met.Therefore, we decided that the Plan has to pre-approve a thigh lipectomy.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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.You asked the Plan to pre-approve SNF care. You say that you need this due to shortness of breath and trouble walking.The Plan denied your request. The Plan says SNF care would exceed your needs.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 care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the records show that you currently have no identifiable skilled nursing needs. While you do have skilled therapy needs, you do not need skilled therapy on a daily basis. You do 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 pre-approve skilled nursing facility (SNF) care.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea Superion spacer.You asked the Plan to pre-approvethese services. You say that the services are medically necessary.The Plan denied your request. The Plan says the services are not medically 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has back pain. The requested Superion spacer is experimental in nature, as more research is needed. It is not the best treatment option for spinal stenosis and should not be used because the safety and efficacy is not proven. The services are therefore not reasonable or medically necessary.We looked at this physician's review, thefile, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pre-approvea Superion spacer.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe Xarelto 15mg tablet medication (J8499).You asked the Plan to pre-approvethis medication. You say that you are requesting a reconsideration of the Plan's denialas the enrollee has been diagnosed with bilateral thrombosis of the femoral veins.The Plan denied your request. ThePlan says that the enrolleehas a medical (MA) only policy with the plan, not a Prescription Drug Plan (PDP). Therefore, coverage is limited to Medicare Part B covered drugs.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drug requested here is not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pre-approvethe Xarelto 15mg tablet medication (J8499).Benefits for this medicationmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency department services provided on November 11, 2019.
You asked the Plan to pay for the emergency department services. You say that you had an accident while traveling to your son's wedding out of the country and you were taken to a local hospital. You say that you had no options to find an in-network provider at the time. The Plan denied your request. The Plan says the Plan does not cover urgently needed service or any other care if the member receives care outside of the United States.
The contract with the Plan says the Plan does not cover urgently needed service or any other care if the member receives care outside of the United States.
We looked at the file and the Plan's rules. The file shows that the Plan does not cover urgently needed services or any other care if the enrollee receives the care outside of the United States. Therefore, we decided that the Plan does not have to pay for the emergency department services provided on November 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not have to pay forarthrocentesis (20610) and fluoroscopic guidance (77002) provided on July 1, 2019.You asked the Plan to pay forthe arthrocentesis and fluoroscopic guidance. You say that you would like reconsideration because CMS indicates that the Plan is the primary payer.The Plan denied your request. The Plan says it is the provider's responsibility to bill the Primary Group Health Plan or any liability insurance before submitting the claim to the member's plan.The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer. The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has requested that the provider to send the bill to the primary insurer. As the secondary insurer, the Plan cannot be held responsible for the arthrocentesis and fluoroscopic guidance until the primary insurer has denied the claim for these services.Therefore, we decided that the Plan does not have to pay forarthrocentesis (20610) and fluoroscopic guidance (77002) provided on July 1, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Tadalafil.
You asked the Plan to pre-approve Tadalafil. You say that you would like the plan to reconsider their denial.
The Plan denied your request. The Plan says the requested drug is not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 Tadalafil.
Benefits for Tadalafil 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: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approveImage Guided Radiotherapy (IGRT).You asked the Plan to pre-approvethe requested services. The Plan denied your request. The Plan says that this treatment is not indicated for the enrollee's cancerThe 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 requested services. Our physician reviewer found that IGRT is a means of using of using daily image guidance to help localize the target so as to minimize normal tissue dosing. IGRT allows accuracy of treatment delivery, so when generating a planning target margin, the margins can be reduced, and thus allow reduction in the volume of normal tissues exposed to radiation. IGRT images can be obtained prior to treatment on a daily basis, and/or before and during radiation. For this enrollee daily imaging would be to verify position prior to every fraction. This is an integrated feature within the LINAC. For this enrollee the treatment field encompasses more than a simple spine metastasis as an abdominal mass is also to be treated in the same field. As the abdominal mass may have more set-up uncertainty due to bowel motion, IGRT would be used to verify target position and allow for better sparing of the bowel. Generally, the dose with palliative radiation is low, such that the normal tissue exposure risks are low, and IGRT is not needed. For this patient, the dose is relatively low, but higher than typical palliative doses, and the target is more than a simple bone metastasis. It is plausible that IGRT will benefit this enrollee and therefore would be medicallynecessary. It would be furnished in accordance with accepted standards of practice. 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 havebeen met. Therefore, we decided that the Plan has to pre-approveImage Guided Radiotherapy (IGRT).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on to the enrollee by an out-of-network
provider on October 31, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not
authorized.
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 services at issue in this appeal. The Plan did not pre-approve the services at
issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that
the Plan does not have to pay for the medical services provided on to the enrollee by an out-of-network
provider on October 31, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approvestereotactic body radiation therapy (SBRT).You asked the Plan to pre-approvethe requested services. The Plan denied your request. The Plan says SBRT is not recommended with patients with four locations of metastatic prostate cancer.The Plan follows Medicare rules. Medicare rules say that stereotactic body radiation therapy is only covered under certain medical indications.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 the enrollee has limited metastatic disease. The complicating issue is that he has 4 (as opposed to 1-3 lesions) for which little data exist. The enrollee does not have primary tumors and tumors metastatic to the lung, liver, kidney, adrenal gland, or pancreas. The enrollee does not have pelvic and head and neck tumors that have recurred after primary irradiation. The enrollee does not have clinically localized, low-to intermediate-risk prostate cancer. It is not indicated that the treatment is for recurrence in or near previously irradiated regions when a high level of precision and accuracy or a high dose per fraction is indicated to minimize the risk of injury to surrounding normal tissues and treatment with conventional methods is not appropriate or safe for this enrollee. Therefore, the requested services are not considered medically 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approvestereotactic body radiation therapy (SBRT).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe impression and custom preparation; oral surgical splint provided on December 10, 2019.You asked the Plan to pay forthe oral surgical splint. You say that the service was medically necessary.The Plan denied your request. The Plan says the documentation submitted did not include documentation of an impression and custom preparation; oral surgical splint. The Plan also says that there is no documentation that the physician, dentist, or other qualified health care professional actually designed and prepared the prosthesis and that it was not prepared by an outside laboratory.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 21085 is not supported in the medical record. Based on this information, we decided that Medicare rules for coverageof the oral surgical splint have not been met.Therefore, we decided that the Plan does not have to pay forthe impression and custom preparation; oral surgical splint provided on December 10, 2019.
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 needs daily labs, physician
oversight, and rehab therapy. The Plan denied your request. The Plan says the enrollee is receiving appropriate
care at the current acute care 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 physician
reviewer found that the enrollee is currently undergoing treatment at an acute care hospital (ACH) for
bacteremia and critical limb ischemia. 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Retacrit.You asked the Plan to pre-approve Retacrit. The Plan denied your request. The Plan says it is unknown if the enrollee has adequate iron stores measure within the last 3 months.The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved 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 Retacrit. Our physician reviewer found that the enrollee has myelodysplastic syndrome (MDS). The notes indicate she has low erythropoietin levels and her iron saturation was 13/5 in May 2020. It was 52% in January 2020. Iron supplements are not listed on the medication lists in the submitted documentation. Retacrit is no FDA approved for use in MDS. Clinical Pharmacology states supplemental iron should be given if the transferring saturation is below 20%.Therefore since the enrollee has low iron saturation, and is not on supplemental iron, the requested use does not meet the guidelines for use.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Retacrit have not been met. Therefore, we decided that the Plan does not have to pre-approve Retacrit.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waivethe copayment for the office visits you had on December 20, 2019, and January 3, 2020.You asked the Plan to waivethe copayments. The Plan denied your request. The Plan says you are responsible for the cost share.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 $35 copayment for each specialist office visit. Review of the file shows that you had specialist visits on December 20, 2019, and January 3, 2020. You have been asked to pay a $35 copayment for each of the visits. The visits fall within the physician services 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 waivethe copayment for the office visits you had on December 20, 2019, and January 3, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveCapecitabine.You asked the Plan to pre-approveCapecitabine. You say that the requested medication is 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 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 Capecitabine. Our reviewer says that the medication is not medically necessary. Our physician reviewer found the prescriber states that the enrollee's age, small size of tumor, node negativity and the Covid-19 pandemic as reasons to avoid Mitomycin which would require IV treatment. Anal Carcinoma do not support the omission of Mitomycin. The planned therapy is with definitive, ie curative intent. The documentation does not indicate the enrollee has had previous radiation or chemotherapy nor that he has low or marginal blood counts. The prescriber has not adequately indicated that use of an unsupported regimen 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 Capecitabine have not been met.Therefore, we decided that the Plan does not have to pre-approveCapecitabine.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient mental health services.You asked the Plan to pre-approvecontinued services. You say that the enrollee is not safe to live alone or in a non-secure facility.The Plan denied your request. The Plan says the enrollee is medically stable, and has no plan or intent to harm self or others.The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. The file shows that continued inpatient services were requested beyond May 25, 2020. 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 services. Our physician reviewer found that it did not appear that active treatment was taking place. It did not appear that the services were reasonably expected to improve the enrollee's condition, or for the purpose of diagnosis. This enrollee was not shown to be a danger to herself or others. She was not showing any auditory or visual hallucinations, and was cooperative/compliant with treatment while not showing any threats the safety or aggressive behaviors.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 services have not been met. Therefore, we decided that the Plan does not have to pre-approvecontinued inpatient mental health services.