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

We decided that the Plan does not have to pre-approveadmission to a skilled nursing facility (SNF).You asked the Plan to pre-approvethe SNF admission. You say that the enrollee would benefit from treatment in a SNF.The Plan denied your request. The Plan says this request is mainly for custodial care due to inability to provide care in the home. Daily skilled services are not required.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 SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the beneficiary is a 93-year-old female with UTI and dementia.From a nursing perspective, the beneficiary received oral medications. The beneficiary had stable vital signs. She received IV fluids. Regarding rehabilitation services, the beneficiary received PT and OT in the acute hospital. The beneficiary was at a minimal to moderate assist level with bed mobility and transfers.
The beneficiary required varying assist with ADLs. She was non-weightbearing to her right foot.There are no identifiable skilled nursing service needs. There are no identifiable 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 SNF admission have not been met.Therefore, we decided that the Plan does not have to pre-approveadmission to a skilled nursing facility (SNF).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to adjust the copayment for the inpatient services provided from
February 26, 2020, to February 27, 2020.
You asked the Plan to adjust the copayment for the inpatient services. You say that you were told you did not
have to pay the inpatient service copayment. The Plan denied your request. The Plan says you were charged
this copayment 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). Your contract with the Plan clearly says that you must pay a $275
copayment for Inpatient Hospital Care, in-network or out-of-network.
You have been asked to pay a $275 copayment for the inpatient services. The inpatient services fall within the
Inpatient Hospital Care 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 adjust the copayment for the inpatient
services provided from February 26, 2020, to February 27, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda 100MG/4ML solution.
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied
your request. The Plan says the clinical value and effectiveness of Keytruda in the setting of combination
therapy with cyclophosphamide for ovarian cancer have not been demonstrated in the peer-reviewed literature.
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 medication. Our physician reviewer
found there is no documentation of MSI-H or dMMR. Of additional note, the requesting physician has
referenced some early data suggesting benefit of a combination of Keytruda, cyclophosphamide, and Avastin.
Because the enrollee cannot tolerate Avastin, the request is for the 2-drug combination. Therefore, the study
noted is not applicable to this enrollee. The clinical value and effectiveness of Keytruda in the setting of
combination therapy with cyclophosphamide for ovarian cancer have not been demonstrated in the peerreviewed
literature. The review has determined that the requested use of Keytruda to be used in combination
with cyclophosphamide is not FDA-approved for the enrollee's diagnosis. The use is not supported by one of
the major drug compendia or by clinical research that appears in a CMS-approved medical journal (see
appendix for list of CMS-approved journals).
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 medication have not been met. Therefore, we decided that the Plan does not
have to pre-approve Keytruda 100MG/4ML solution.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea CardioMEMS system (33289, C2624).You asked the Plan to pre-approvea CardioMEMS system. You say that the services are necessary.The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not been met.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 a CardioMEMS system. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found in this circumstance therapy change based on data obtained from a CardioMEMs device has been demonstrated in only one randomized prospective trial to help reduce hospital readmission compared to standard medical therapy. Moreover, concerns have been raised about potential bias in this trial calling into question the results. Therefore, the efficacy of the CardioMEMS device is uncertain at this time according to leading authorities and not recommended in current guidelines for the treatment of heart failure. Medicare coverage criteria are not met since the device should still be considered experimental or investigational.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 CardioMEMS system have not been met.Therefore, we decided that the Plan does not have to pre-approvea CardioMEMS system (33289, C2624).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the records provided support the need for IRF care. 
The Plan denied your request. The Plan says rules for IRF care have 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 that the complexity of your nursing, medical and rehabilitation needs does not require 
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. The medical record supports a need for physical and occupational therapy but it 
does not support a need for an intensive rehabilitation therapy program. There is not a reasonable expectation 
that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an IRF. 
 
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 IRF admission and services.
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 you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested admission is not medically necessary.
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 enrollee required contact guard assistance for bed mobility, transfers, and walking up to 40 feet. The enrollee required minimal to maximum assistance for activities of daily living. The documentation does not support that the enrollee requires an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not support that the enrollee requires an intensive rehabilitation therapy program. The enrollee's care needs can be met at a lower 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 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 pay forthe medical services provided to the enrollee by an out-of-network provider on December 17, 2019.You asked the Plan to pay forthe 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 forthe medical services provided to the enrollee by an out-of-network provider on December 17, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approveadditional routine transportation (A0120).You asked the Plan to pre-approveadditional routine transportation. You say that you are requesting a reconsideration of the Plan's denial.The Plan denied your request. The Plan says you have exhausted the allowable routine transportation benefit.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 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-approveadditional routine transportation (A0120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the occlusal guard (D9944) provided on July 6, 2020.
You asked the Plan to pay for the occlusal guard. You say that you would like an exception made, and for the
guard to be covered. The Plan denied your request. The Plan says this service is not covered by the Plan.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the
occlusal guard (D9944) provided on July 6, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-share for the services provided.


You asked the Plan to waive the cost-share for the services. You say that you had called the Plan prior to having the services rendered and had been advised that you would be covered for the services.The Plan denied your request. The Plan says they reviewed your phone calls to the Plan and confirmed that you were not provided incorrect benefit information.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co payments, deductibles and coinsurance). 

Review of the file shows that you received outpatient surgical services and physical therapy. Therefore, you are asked to pay 20% coinsurance for the outpatient surgical services and a $35 copayment for physical therapy. Your EOC states that you must pay 20% coinsurance for outpatient surgery, both in-network and under your POS benefit, a $35 co payment for outpatient therapy services, such as physical and occupational therapy. You pay these amounts until you reach the $5,000 in-network and $10,000 out-of-network out-of-pocket maximums. 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 cost-share for the services provided.
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 requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.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 enrollee does not meet criteria for IRF admission. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for a fall with subsequent rhabdomyolysis and encephalopathy. Medical problems are stable. There are no identified problems that need inpatient medical management. There are no complex nursing or rehabilitation needs.The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, in an intensive rehabilitation therapy program. The medical record supports a need for physical and occupational therapy but it does not support a need for an intensive rehabilitation therapy program. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 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
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forgenetic testing provided on June 11, 2020.You asked the Plan to pay forthe genetic testing. You say that you would like reconsideration because this testing is medically necessary to help estimate the member's risk to develop medical conditions and will directly impact their medical management.The Plan denied your request. The Plan says if a single procedure is performed, only one CPT code with one unit of service may be reported for the procedure.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 documentation does not show that the requested pharmacogenomic testing was ordered due to any signs/symptoms of a drug reaction. There is no evidence that the testing was provided for therapeutic decision-making regarding the need for the use of any specific drug. This means that this extended panel was provided for screeningpurposes, and this type of testing is not among those covered by Medicare for screening.Therefore, we decided that the Plan does not have to pay forgenetic testing provided on June 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablations (RFA) of the facet joints.
You asked the Plan to pre-approve RFAs. You say that the enrollee and you believe that medial branch RFAs
are the best method to treat the enrollee's pain. The Plan denied your request. The Plan says the denial of
authorization for these services is correct, because the enrollee underwent 2 diagnostic medial branch blocks
with documented pain relief of only 30%.
The Plan follows Medicare rules. Medicare rules state that RFAs may be considered only when dual medial
branch blocks provide significant relief of pain and duration of relief is consistent with the agent employed.
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 RFAs. Our reviewer says that the
enrollee does not meet the Medicare criteria for the requested RFAs. Our physician reviewer found the enrollee
underwent 2 sets of bilateral lumbar medial branch blocks. On one set she achieved only 30% pain relief,
however the diagnostic medial branch blocks must each achieve at least 80% pain relief. Therefore, this request
is not medically reasonable or 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 RFAs have not been met. Therefore, we decided that the Plan does not have to
pre-approve radiofrequency ablations (RFA) of the facet joints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe 2D oral or facial images (D0350), the initial 15 minutes of conscious sedation (D9239), and the additional 15 minutes of conscious sedation (D9243 x 3) provided on May 20, 2020.You asked the Plan to pay forthe dental services. You say that The provider says that intravenous (IV) sedation is recommended to people who are having an invasive procedure. The provider says you have high dental anxiety. The provider says that your dental phobia causes significant distress and interferes with your ability to keep calm during an intensely methodical procedure. The provider also says IV sedation will also manage any hypertension or medical issues during dental surgery.The Plan denied your request. The Plan says the 2D oral or facial images are not listed as acovered service. The Plan says conscious sedation is not listed as a covered service either.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  services you received are not among those covered under this benefit. The Evidence of Coverage clearly states that any services not listed are not covered.Therefore, we decided that the Plan does not have to pay forthe 2D oral or facial images (D0350), the initial 15 minutes of conscious sedation (D9239), and the additional 15 minutes of conscious sedation (D9243 x 3) provided on May 20, 2020.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve Excision Excessive Skin and Subcutaneous Tissue.
You asked the Plan to pre-approve Excision Excessive Skin and Subcutaneous Tissue. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says that the requested services are not medically necessary.
The Plan follows Medicare rules. Medicare rules say that Excision Excessive Skin and Subcutaneous Tissue is only covered when 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 Excision Excessive Skin and Subcutaneous Tissue. Our reviewer says that the documentation does support that the requested services are medically reasonable or necessary. Our physician reviewer found that you have evidence of functional impairment related to an abdominal pannus. Your functional impairment includes rashes, skin irritation, difficulty with ambulation and knee pain due to the size of the abdominal pannus. The effect on your knee pain is supported by Orthopedic surgery. You have attempted to treat her functional impairment of chronic rashes with proper hygiene and is under the care of Orthopedics to treat your chronic knee pain. Photographs appear to support your likely chronic functional impairment. From Medicare, the rules say that medically necessary services are those that are reasonable and necessary for the diagnosis or treatment of an illness or injury. Medically necessary services include services to improve the functioning of a malformed body member. Thus, panniculectomy for you directly satisfies Medicare medically necessary criteria. You have evidence of significant functional impairment related to your overhanging lower abdominal pannus that would likely improve with panniculectomy. Therefore, you meet criteria for the requested 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 Excision Excessive Skin and Subcutaneous Tissue have been met. Therefore, we decided that the Plan has to pre-approve Excision Excessive Skin and Subcutaneous Tissue.
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.