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

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care beyond
January 29, 2020.
You asked the Plan to pre-approve the continued SNF care. You say that the enrollee continues to require daily
skilled therapy for her condition. The Plan denied your request. The Plan says the enrollee has not experienced
improvement in the stay so far and maintenance of her current level of function does not require daily skilled
care.
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 continued SNF care. Our reviewer
says that daily skilled services are not necessary. Our physician reviewer found the beneficiary is a 90 year old
female admitted to the SNF. From a nursing perspective, the beneficiary received oral, topical and ophthalmic
medications. The beneficiary had stable vital signs. She was incontinent of bowel and bladder. She had
uncomplicated wound care to her coccyx. She tolerated a regular diet and thin liquids. Regarding rehabilitation
services, the beneficiary received PT and OT in the SNF. By the dates in question, the beneficiary was at a
moderate to maximal assist level with functional mobility including gait to 23 feet with a rolling walker. The
beneficiary required varying assist with ADLs.
There are no identifiable ongoing skilled nursing service needs. There are no identifiable ongoing 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 continued SNF care have not been met. Therefore, we decided that the Plan
does not have to pre-approve continued skilled nursing facility (SNF) care beyond January 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe outpatient clinic visits and CT scan provided on January 16, 2019, February 19, 2019 and March 7, 2019.You asked the Plan to waive the coinsurance forthe outpatient clinic visits and CT scan. You say that you were already a patient and continued to receive care there. You say that the claims should be processed in-network.The Plan denied your request. The Plan says the out-of-network coinsurance applied correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay 30% coinsurance for provider and professional services at an out-of-network outpatient hospital and 30% coinsurance for advanced imaging services at an out-of-network outpatient hospital.The enrollee has been asked to pay a total of $259.17, which is less than the standard 30% coinsurancefor the outpatient clinic visits and CT scan. The outpatient clinic visits fall within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The CT scanfalls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan.Therefore, we decided that the Plan does not have to waive the coinsurance forthe outpatient clinic visits and CT scan provided on January 16, 2019, February 19, 2019 and March 7, 2019
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the portable oxygen concentrator provided on October 30, 2019 by the out of network provider.
You asked the Plan to pay for the portable oxygen concentrator. You say that you need the portable oxygen concentrator for when you go to the store and travel by plane. The Plan denied your request. The Plan says you did not get prior authorization for the out-of-network provider.
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 the portable oxygen concentrator provided on October 30, 2019 by the out of network provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission
You asked the Plan to pre-approve these services. You say that the enrollee needs assistance. The Plan denied your request. The Plan says the admission 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 to pre-approve these services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to the hospital on January 22, 2020 with weakness and frequent falls. He received oral medications and had stable vital signs. He received physical therapy in the hospital and needs stand-by to contact guard assist with functional mobility, including gait to 360 feet with a rolling walker. He has no skilled nursing needs. He has skilled therapy needs but does not require skilled therapy on a daily basis. As a practical matter, the enrollee does not require the necessary services on an inpatient basis at the 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda (pembrolizumab) treatments.

You asked the Plan to pre-approve the Keytruda treatments. You say that this immunotherapy should be allowed due to progression with Votrient. The Plan denied your request. The Plan says there is no support for the effectiveness of this drug for the enrollee's disease.

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 Keytruda treatments. Our reviewer says that the requested treatment is not considered reasonable and necessary in this case. Our physician reviewer found this review relates to a request for Pembrolizumab for a 73 year old man with metastatic high grade liposarcoma that is microsatellite stable/mismatch repair proficient. The drug is not FDA approved for the requested use. The drug is not supported in any of the CMS compendia for the requested use. This reviewer found no supportive citations for use of Pembrolizumab to treat liposarcoma. 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 Keytruda treatments have not been met. Therefore, we decided that the Plan does not have to pre-approve Keytruda (pembrolizumab) treatments.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the root canal (D3320) provided on August 8, 2019.
You asked the Plan to pay for the dental service. You say that you did not have time before your heart surgery to find an in network dentist. The Plan denied your request. The Plan says the root canal is not a covered service.
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 root canal is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the root canal (D3320) provided on August 8, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve powered pressure-reducing air mattress (E0277).
You asked the Plan to pre-approve powered pressure-reducing air mattress. You say that your mattress gets hot which is causing the bed sores and you need a new one to replace the old mattress. You met the requirements for the bed you should meet the requirements for the mattress. The Plan denied your request. The Plan says member's condition does not meet the Medicare medical necessity coverage criteria for a group 2 power reducing mattress.
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 powered pressure-reducing air mattress. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is not shown to have multiple stage II ulcers on the trunk/pelvis, to have a large or multiple stage III or IV ulcer(s) on the trunk/pelvis or to have a myocutaneous flap/skin graft on a pressure ulcer of the trunk/pelvis. Therefore, the requested air mattress does not meet coverage criteria. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of powered pressure-reducing air mattress have not been met. Therefore, we decided that the Plan does not have to pre-approve powered pressure-reducing air mattress (E0277).
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve a mandibular partial denture (D5226).You asked the Plan to pre-approve the dental item. You say that supra-eruption of the upper left will occur as there are no opposing teeth. You say that eventually teeth may have to be extracted. You also say that since tooth # 19 was recently extracted, there is no longer proper molar chewing function on the left side.The Plan denied your request. The Plan says that there is enough dentition remaining that would allow for adequate mastication.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the dental item when the services are medically necessary and reasonable.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 dental item. Our reviewer says that the partial denture meets the criteria for coverage. Our physician reviewer found the Plan does not provide any further guidance on limitation of partial dentures other than the tooth must have been removed and was a covered extraction under the Plan. The documentation shows the other teeth are in good condition and that the partial denture would stabilize the arch and the prevention of super-eruption of the opposing teeth. As there are no limitations provided by the Plan other than the tooth having been removed as a covered service, for which there is no indication that it was not, the request is found to meet criteria.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental item have been met.Therefore, we decided that the Plan has to pre-approvea mandibular partial denture (D5226)
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided July 25, 2019 to August 3, 2019.
You asked the Plan to pay for the SNF services. You say that you feel that the plan should cover for SNF services. The Plan denied your request. The Plan says medical necessity cannot be established for continued SNF level of coverage.
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 pay for the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing and skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis and 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 services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided July 25, 2019 to August 3, 2019.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay forthe anesthesia for femur surgery, and the special anesthesia service provided on September 25, 2019.You asked the Plan to pay forthe anesthesia services. You say that the enrollee's hospice status ended on September 23, 2019.The Plan denied your request. The Plan says the Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation.Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated.The enrollee ended Medicare Hospice benefits on September 23, 2019. The services in question were provided before the end of that month.Therefore, we decided that the Plan does not have to pay forthe anesthesia for femur surgery, and the specialanesthesia service provided on September 25, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve computed tomography angiography (CTA) scans of the abdomen and pelvis for the enrollee.
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 codes 72191 and 74175 are not approved.
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well. The requested services are an abdomen CTA described by code 74175 and a pelvic CTA described by code 72191. The Plan has approved a CTA of the abdomen/pelvis under code 74174. Codes 74175 and 72191 are column II codes with a modifier indicator of 1 when billed with column I code 74174 and are not separately payable. The Plan has appropriately approved the services under code 74174. Therefore, we decided that the Plan does not have to pre-approve computed tomography angiography (CTA) scans of the abdomen and pelvis for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the specialist office visits provided on August 22, 2019 and August 29, 2019.
You asked the Plan to waive the copayments for the specialist office visits. You say that you should not have a pay a $30 copayment to get your medications. 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 $30 copayment per specialist office visit. You have been asked to pay a $30 copayment for each of the specialist office visits. The specialist office visits fall within the "Physician/Practitioner services, including doctor's office visits" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for the specialist office visits provided on August 22, 2019 and August 29, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM).
You asked the Plan to pre-approve the CGM. You say that the enrollee would benefit from the requested CGM for control of her diabetes. The Plan denied your request. The Plan says the coverage criteria for this device are not met.
The Plan must follow Medicare rules. Medicare rules say that CGMs are covered by Medicare only when specific criteria are met, including testing blood glucose levels four or more times per day and requiring three or more daily insulin injections. In this case, the medical records do not document the frequency of glucose testing or insulin injections. The prior authorization form indicates that glucose testing is done three times per day and that a single insulin dose is provided daily. Based on this information, the criteria for Medicare coverage of the CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM).
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for Emergency Room Services provided on May 5 to May 8, 2019.
You asked the Plan to waive the copayment for the Emergency Room Services. You say that the copayment
should be waived. The Plan denied your request. The Plan says the correct copayment has been applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees
must pay a $65 copayment for Emergency Care.
The enrollee has been asked to pay a $65 copayment for the Emergency Room Services. The Emergency Room
Services fall within the Emergency Care benefit category. This means that the enrollee has been asked to pay
the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee
agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the
copayment for Emergency Room Services providedon  May 5 to May 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvemedical nutrition therapy services.You asked the Plan to pre-approvemedical nutrition therapy services. 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.The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services only for enrollees with renal disease or diabetes. Records do not show that you suffer from renal disease or diabetes.Therefore, we decided that the Plan does not have to pre-approvemedical nutrition therapy services.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance servicesand ground mileage provided on August 7, 2019.You asked the Plan to pay forthe transportation services. You say that according to Medicare, the enrollee was not enrolled inhospice at the time the services were rendered. You say that Medicare advised the enrollee was not enrolled in hospice until August 16, 2019.The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as itis responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked.Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated.The enrollee ended Medicare Hospice benefits on August 7, 2019 and re-enrolled on August 16, 2019. The services in question were provided before the end of that month.Therefore, we decided that the Plan does not have to pay forthe ambulance services and ground mileage provided on August 7, 2019.
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-approveIRF care. You say that you need admission to IRF for intensive therapies to rehabilitate faster and return home.The Plan denied your request. The Plan says the denial of authorization for IRF service is correct.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found you do not require the intensity of services provided at an IRF. Specifically, you are not shown to be able to perform 15 hours per week of rehabilitative services with regular physician evaluation. Your care needs can be met at a lower level of care such as skilled nursing facility.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-approveacute inpatient rehabilitation facility (IRF) admission and services.