Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from May 20, 2019 through May 24, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that the stay was medically necessary. The Plan denied your request. The Plan says that the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the review has determined that the record showed that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergency department (ED) and/or observation care) would span two midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from May 20, 2019 through May 24, 2019.
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a cone beam CT scan with interpretation and report (D0366), the surgical placement of an implant body (D6010), a custom fabricated abutment (D6057), an abutment supported crown (D6059), and a bone replacement graft for ridge preservation (D7953).
You asked the Plan to pre-approve the dental services. You say that you hit your face on the freezer door. You say that this resulted in your tooth with a crown being knocked out. You say that you were treated for this by an emergency dentist on April 7, 2020. You also say that the implant is needed as it was one of your front teeth. The Plan denied your request. The Plan says the dental services that you requested are not listed as covered services.
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 dental services are not among those listed as covered under this benefit. Additionally, the Evidence of Coverage clearly states that any services not listed are not covered. Therefore, we decided that the Plan does not have to pre-approve a cone beam CT scan with interpretation and report (D0366), the surgical placement of an implant body (D6010), a custom fabricated abutment (D6057), an abutment supported crown (D6059), and a bone replacement graft for ridge preservation (D7953).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forSkilled Nursing Facility (SNF) care provided from August 17, 2018 to September 15, 2018.You asked the Plan to pay forSNF care. You say that you are appealing for payment of this claim.The Plan denied your request. The Plan says the denial of payment for SNF service is correct.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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee did not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a Skilled Nursing Facility (SNF) 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 forSkilled Nursing Facility (SNF) care provided from August 17, 2018 to September 15, 2018.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea tall wheelchair.You asked the Plan to pre-approvea tall wheelchair. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested item is not medically necessary.The Plan follows Medicare rules. Medicare rules say that a manual wheelchair is only covered for certain 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 a tall wheelchair. Our reviewer says that the documentation does not support that the requested tall wheelchair is medically reasonable or necessary. Our physician reviewer found you are noted to have a mobility deficit but are a functional ambulator and there is no evidence that your mobility deficit significantly impairs mobility related activities of daily living in the home. Your mobility deficit can be resolved currently with a front wheeled walker and your current manual wheelchair. The documentation does not support that you will use this wheelchair on a regular basis in the home. The DME consultation notes that your current manual wheelchair is used infrequently and is in good condition at this time. Your walker is also noted in good condition. There is no indication for the provision of a new wheelchair at this time as your current one meets your needs for infrequent dependent transport. Per the documentation, you are able to safely operate the current manual wheelchair and there is no indication from the durable medical equipment (DME) consultation that a high back wheelchair will significantly improve the your ability to participate in mobility related activities of daily living over your current DME.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a tall wheelchair have not been met.Therefore, we decided that the Plan does not have to pre-approvea tall wheelchair.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean Epifix skin graft (Q4186, 15275).You asked the Plan to pre-approvean Epifix skin graft. You say that the enrollee's ulcer is not healing and this is the only way to  treat it.The Plan denied your request. The Plan says this is not covered for the enrollee's condition.The Plan must follow Medicare rules. Medicare rules say that amniotic membrane derived skin substitutesoutside of the care of venous stasis ulcers and diabetic foot ulcersas not reasonable and necessary and non-covered.We looked at the file and Medicare rules. The record does not show that the enrollee has either a venous stasis ulcer or adiabetic foot ulcer.Based on this information, we decided that Medicare rules for coverage of an Epifix skin graft have not been met.Therefore, we decided that the Plan does not have to pre-approvean Epifix skin graft (Q4186, 15275).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient mental health services provided from January 1,
2020 to January 8, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says care could have been
provided at the observation level.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the
patient requires active treatment.
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 services. Our reviewer says that the
requested inpatient mental health care was not medically reasonable and necessary. Our physician reviewer
found that it was not expected this enrollee would improve in a reasonable period of time as he did not have
dangerousness to self or others, auditory or visual hallucinations, delusions and was not showing any
behavioral issues. It was not medically necessary and reasonable to have psychiatric care provided at the acute
inpatient level of care rather than a lower level of care as he did not have dangerousness to self or others,
perceptual disturbance including auditory or visual hallucinations.
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 Plan does not
have to pay for the inpatient mental health services provided from January 1, 2020 to January 8, 2020.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Zarxio (Q5101). 
 
You asked the Plan to pre-approve Zarxio. You say that the medication is necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria for a step therapy exception has not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Zarxio. Our reviewer says that the medication is not medically necessary. Our physician reviewer found the documentation does not support that Neupogen (Filgrastim) and Nivestym (Filgrastim-aafi) would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Zarxio have not been met. Therefore, we decided that the Plan does not have to pre-approve Zarxio (Q5101).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray services coded 71045 provided on February 20, 2020. You asked the Plan to pay for the x-ray services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.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 71045 is radiologic examination, chest; single view. We find that CPT code 71045 is not supported in the medical record. Specifically, the documentation supports three units of this code were provided. Three units of this code have already been previously approved/paid by the plan. Based on this information, we decided that Medicare rules for coverage of the x-ray services have not been met. Therefore, we decided that the Plan does not have to pay for the x-ray services coded 71045 provided on February 20, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips (A0120).
You asked the Plan to pre-approve additional routine transportation trips. You say that the requested additional transportation is necessary. The Plan denied your request. The Plan says the requested additional transportation trips exceed the benefit limit. Therefore, coverage criteria has not been met.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 30 one-way transportation trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation trips (A0120).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forinpatient hospital care provided to the enrollee from January 1, 2020 through January 2, 2020.You asked the Plan to pay foracute inpatient hospital 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 inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the review has determined that the record did not show that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergency department (ED) and/or observation care) would span two midnights. We looked at this physician's review, the file, and Medicarerules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met.Therefore, we decided that the Plan does not have to pay forinpatient hospital care provided to the enrollee from January 1, 2020 through January 2, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Computed Tomography (CT) of the chest (71250).
You asked the Plan to pre-approve the CT scan. You say that the CT 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 CT 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 CT scan. Our reviewer says that the CT scan is not medically necessary. Our physician reviewer found the patients symptoms are not currently worsening and there is an explanation for her exertional dyspnea based on pulmonary function tests and her COPD diagnosis. 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 CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve Computed Tomography (CT) of the chest (71250).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on July 30, 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 services are 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 July 30, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 36 additional routine transportation trips.
You asked the Plan to pre-approve 36 additional trips. You say that you are requesting additional trips to be
covered in order to continue treatment that you have started. Medical will not cross the state line. The Plan
denied your request. The Plan says this request exceeds the benefit limitations.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this
case. The Plan covers a maximum of 48 trips per year.
We looked at your request, the records in the case file, and the rules. Based on this information, we decided
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we
decided that the Plan does not have to pre-approve 36 additional routine transportation trips.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Part B injections provided on March 3, 2020.
You asked the Plan to waive the coinsurance for the Part B injections. You say that you were charged for operating services and this service was performed in an office setting. 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 20% coinsurance for Part B drugs including chemotherapy drugs. You have been asked to pay $399 which is 20% of the allowed amount for the Part B injections. The allowed amount is $1,995. ($1,995 x 20% = $399). The Part B injections fall within the "Medicare Part B prescription drugs" 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 coinsurance for the Part B injections provided on March 3, 2020.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approveCarboplatin, Paclitaxel, and supporting drugs Ondansetron and Dexamethasone.You asked the Plan to pre-approvethe requested drug regimen. You say that the enrollee is not a surgical candidate.The Plan denied your request. The Plan says that the regimen of Carboplatin and Paclitaxel used to treat squamous cell skin cancer is not supported in compendia.The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the requested drug regimen. Our physician reviewer found that the enrollee has squamous cell carcinoma of the ear. He is post mastoidectomy and left craniectomy. There has been a recurrence into the resection bed with involvement of the bone and surrounding area. The requested use of the drug regimen is supported by one of the major drug compendia. Therefore, the requested drug regimen is 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 drug regimen have been met.Therefore, we decided that the Plan has to pre-approveCarboplatin, Paclitaxel, and supporting drugs Ondansetron and Dexamethasone.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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve semi-electric hospital bed (E0260). You asked the Plan to pre-approve semi-electric hospital bed. You say that please review the attached chart note and reconsider denial of order for hospital bed.The Plan denied your request. The Plan says the LCD criteria for approval for semi electric hospital bed has not been met The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered medically necessary when the patient:1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or2. Requires attachments which can only be attached to a hospital bed; AND3. Requires frequent changes in body position and/or has an immediate need for a change in body position.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 semi-electric hospital bed. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee's condition does not require positioning of the body in ways not feasible in an ordinary bed. There is no evidence she is unable to perform a weight shift. The 3/23/20 document notes that she is starting to not walk as much and the documentation does not reveal that the enrollee requires a special attachments that cannot be fixed and have been attempted on an ordinary bed. The enrollee lives in a memory care unit and is noted to need assist to move from bed to chair. There is no evidence that she is unable to be assisted without special attachments. A semi-electric hospital bed is not medically necessary for this 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 semi-electric hospital bed have not been met.Therefore, we decided that the Plan does not have to pre-approve semi-electric hospital bed (E0260).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair. 
 
You asked the Plan to pre-approve a shower chair. You say that you want to appeal the Plan's denial of the requested shower chair. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.