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

We decided that the Plan does not have to pre-approveskilled nursing facility (SNF) care.You asked the Plan to pre-approveSNF care. You say that the services 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. 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 applythe 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 there are skilled needs, but they do not need tobe provided on a daily basis. The enrollee's care can be appropriately provided through home-based and outpatient services.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met.Therefore, we decided that the Plan does not have to pre-approveskilled nursing facility (SNF) care.
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 the services 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. 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 provided medical records do not indicate a
need for daily skilled services or inpatient services. Care in a nursing facility with custodial care or in the home
or an assisted living facility with home health services appears to be appropriate.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Action Trackchair for the enrollee. You asked the Plan to pre-approve an Action Trackchair. The Plan denied your request. The Plan says that this does not meet the definition of a specific power operated vehicle/power wheelchair. The Plan must follow Medicare rules. Medicare rules say that POV/PWC coded as K0899 will be denied as not reasonable and necessary. We looked at the file and Medicare rules. The Action Trackchair is coded K0899. Based on this information, we decided that Medicare rules for coverage of an Action Trackchair have not been met. Therefore, we decided that the Plan does not have to pre-approve an Action Trackchair for the enrollee.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the services are necessary.The Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not been met.The Plan must follow Medicare rules. The rules say that IRFadmission 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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer found you have therapy and medical needs that meet criteria for acute level rehabilitation.Care at a lower level would not effectively meet your rehabilitation 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 IRF care have been met.Therefore,we decided that the Plan has to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.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 toopen the case again, we will send you a letter.
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 services 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. 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 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 based on the medical records provided the
enrollee does not require treatment in an intensive rehabilitation therapy program. Based on the medical
records provided there is no concern that the enrollee would not be able to fully participate but there does not
appear to be a need for the intensive rehabilitation therapy program provided in an inpatient rehabilitation
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-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 deductible forthe out-of-network physician services provided on August 29, 2019.You asked the Plan to waive the deductible fortheout-of-network physician services. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request.The Plan denied your request. The Plan says you received out-of-network physicianservices on the date of service at issue in this appeal. The Plan states the correct amount has applied towards your deductible per your contract with the Plan.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is $1000 deductible that must be met before the Plan will pay their share for Physician/Practitioner services. The item or service you asked the Plan to waive the deductible for falls within thebenefit category Physician/Practitioner services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $1000 deductible that must be met before the Plan will pay their share for Physician/Practitioner services. This cost sharing is a contractual obligation that had not been met at the time the out-of-network physician services were received on August 29, 2019.Therefore, we decided that the Plan does not have to waive the deductible forthe out-of-network physician services provided on August 29, 2019.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to waive the copayment forthe laboratory services provided on August 29, 2019.You asked the Plan to waive the copayment forthe laboratory services. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request.The Plan denied your request. The Plan says that you received laboratory services on the date of service at issue in this appeal that went beyond the services included in your annual wellness visit. The Plan states 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 does not say in clear and accurate terms how much you should expect to pay for Outpatient diagnostic tests. We looked at your contract with the Plan. We did not see where the contract says enrollees must pay a $15 copayment for Outpatient diagnostic tests. The Plan contract says you can expect to pay a $0 to $15 copayment for Outpatient diagnostic tests. The Plan contract does not clearly say how much enrollees must pay for Outpatient diagnostic tests specifically. This means that the Plan did not follow Medicare rules for disclosure of cost sharing information.Therefore, we decided that the Plan has to waive the copayment forthe laboratory services provided on August 29, 2019.If the Plan does not agree with our decision,they can ask us to open a case again. We only open a caseagain 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: Surgery
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvebilateral upper eyelid blepharoplasty for the enrollee.You asked the Planto pre-approvethe surgery. You say that this is medically necessary.The Plandenied your request. The Plansaysthe photographs do not demonstrate the eyelid abnormalities that would necessitate the procedure.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 surgery. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found edicare criteria were not met for upper eyelid blepharoplasty based the supporting photographs. The health plan argument that photographs do not support the need for surgery is justified. The photographs do not support the MRD listed as 0 mm.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 surgery have not been met.Therefore, we decided that the Plandoes not haveto pre-approvebilateral upper eyelid blepharoplasty for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea Positron Emission Tomography (PET) scan.You asked the Plan to pre-approvethe PET scan. You say that the PET scan is medically necessary.The Plan denied your request. The Plan says rules for coverage are not met.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 the PET scan. Our reviewer says that coverage criteria has not been met. Our physician reviewer found in this case, since fronto-temporal dementia (FTD) is not part of the differential diagnosis, the requested brain imaging, positron emission tomography (PET) scan 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 PET scan have not been met.Therefore, we decided that the Plan does not have to pre-approvea Positron Emission Tomography (PET) scan.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the services 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. 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 there is no reason to think that an intensive rehabilitation therapy program would significantly impact the enrollee's condition differently compared with therapy provided at a less intense level. The enrollee's care can be provided through home-based and outpatient care.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage ofIRF care have not been met.Therefore, we decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent hospital care (99309) provided by out of network provider on July 18, 2019.
You asked the Plan to pay for these services. You say that the provider rendered medically necessary services to the member in good faith. The Plan denied your request. The Plan says the member's primary care physician did not refer for these services. The plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.
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 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 service 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 subsequent hospital care (99309) provided by the out of network provider on July 18, 2019.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approvePositron Emission Tomography (PET) (78815).You asked the Plan to pre-approvethe PET scan. You say that the PET scan is medically necessary.The Plan denied your request. The Plan says that rules for coverage were not met.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 the PET scan. Our reviewer says that coverage criteria has been met. Our physician reviewer found three FDG PET scans are nationally covered when used to guide subsequent management of anti-tumor treatment strategy after completion of initial anti-cancer therapy. This is second and is medically appropriate.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 PET scanhave been met.Therefore, we decided that the Plan has to pre-approvePositron Emission Tomography (PET) (78815).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 wasa 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for Cataract surgery (66984RT, J1097)
provided October 10, 2019.
You asked the Plan to waive the copayment for the cataract surgery. You say that the copayment should be
waived The Plan denied your request. The Plan says the correct cost share was 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). Your contract with the Plan clearly says that you must pay a $300
copayment for outpatient surgery and a 20% coinsurance for Part B drugs.
You have been asked to pay a $300 copayment for outpatient surgery and a 20% coinsurance for Part B drugs
administered with the procedure. 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 Cataract surgery
(66984RT, J1097) provided October 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services provided on October 15, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the supporting documentation received does not match the date of service.The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. Welooked at the file and Medicare rules.The documentation submitted does not contain records for date of service October 15, 2019. Without these records, it cannot be determined that Medicare coverage criteria have been met.Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plan does not have to pay forthe services provided on October 15, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 25mg Jardiance tablets.
You asked the Plan to pre-approve the Jardiance. You say that you would like reconsideration because the
member is controlled on Jardiance. The Plan denied your request. The Plan says the service or item in question
is not covered under the member's contract under any normal circumstances.
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 25mg Jardiance tablets.
Benefits for the Jardiance 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for panoramic x-rays provided  on May 21, 2019.
You asked the Plan to pay for the x-rays. You say that the physician did more that actually get the whole mouth to ensure proper procedure of broken teeth to be removed. You did not request this The Plan denied your request. The Plan says this service is limited to once every 36 months.
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. Per the Dental Benefits Guide, full mouth set of x-rays are limited to one every 3 years. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for panoramic x-rays provided on May 21, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approvePadcev.You asked the Plan to pre-approvePadcev. You say that the requested Padcev is medically necessary.The Plan denied your request. The Plan says the requested Padcev is not medicallynecessary.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 Padcev. Our reviewer says that the requested Padcev is not medically necessary. Our physician reviewer found the enrollee is with metastatic bladder cancer status post immunotherapy. The enrollee never had chemotherapy due to creatinine levels. Per the FDA label, Padcev is approved after both platinum-containing chemotherapy (CDDP)and immunotherapy have been tried and failed. The documentation shows that the enrollee has never had a platinum agent. Dose adjusted carboplatin could be used. The requested Padcev is not 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 Padcev have not been met.Therefore, we decided that the Plan does not have to pre-approvePadcev
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services (G0483) provided to the enrollee on July 3, 2019.
You asked the Plan to pay for the drug testing services. The Plan denied your request. The Plan says the billed service cannot be verified.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code G0483 is "Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed". We find that CPT code G0483 is not supported in the medical record. Specifically, the records provided do not support that more than 22 or more drug classes were tested on the date of service in question. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services (G0483) provided to the enrollee on July 3, 2019