Persius/hicric huggingface dataset:
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 these services are medically necessary. The Plan denied your request. The Plan says that the therapies you are requesting can be provided in the skilled nursing facility.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.

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. You do not require the intensity of services provided at an IRF. Specifically, you are not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. Your care needs can be met at a lower level of care. Our physician reviewer found that your condition does not meet Medicare criteria for IRF 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Lumigan Solution 0.01%.

You asked the Plan to pre-approve the Lumigan Solution. You say that you would like reconsideration because the member has had an adverse reaction to the generic formula of the requested drug. The Plan denied your request. The Plan says this drug does not fall under Medicare Part B.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered 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 Lumigan Solution 0.01%.

Benefits for the Lumigan Solution 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: Step-Therapy
Decision: Favorable

We decided that the Plan has to pre-approve Eylea for the enrollee.

You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your
request. The Plan says that this request does not meet the step therapy criteria.

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 the drug. Our reviewer says that the
requested drug is medically reasonable and necessary. Our physician reviewer found the major compounder of
Avastin (bevacizumab) in the United States has recently shut down distribution of the required step therapy
drug. Consequently, there is a shortage of Avastin. As the enrollee's ophthalmologist documents that she is
unable to treat the enrollee in a timely fashion, the step therapy criteria for Avastin should be waived, in order
to prevent vision loss, until an alternative source of Avastin is readily available.

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 drug have been met. Therefore, we decided that the Plan has to pre-approve
Eylea for the enrollee.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that 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 in the Medicare rules section 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 enrollee does not have documented skilled
nursing needs. The enrollee does not have documented skilled therapy needs. Daily skilled services are not
shown to be required to establish a maintenance program or to prevent deterioration of the enrollee's condition.
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: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the echocardiography (CPT code 93306) and the duplex scan of extracranial arteries; complete bilateral study (CPT code 93880) provided on July 1, 2020, by an out-of-network provider.
You asked the Plan to waive the copayment for the services. You say that you are questioning why you have two copayments of $160 each on the same date of service at the same doctor's office. The Plan denied your request. The Plan says the claim was processed accordingly with your 2020 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance).
Review of the file show that you received an echocardiography (CPT code 93306) and the duplex scan of extracranial arteries; complete bilateral study (CPT code 93880) on July 1, 2020. You were asked to pay a $160 copayment for each service received. Your 2020 EOC states enrollees must pay a $160 copayment for each Medicare-covered radiological diagnostic service, not including X-rays, performed in a physician's office or at a free-standing facility (such as a radiology center or medical clinic). 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 the echocardiography (CPT code 93306) and the duplex scan of extracranial arteries; complete bilateral study (CPT code 93880) provided on July 1, 2020, by an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that the enrollee requires wound care and assessments multiple times a day. Continued therapy services are required, and the requested LTACH is highly successful for patient recovery. The Plan denied your request. The Plan says the requested LTACH services are not medically necessary, reasonable, or appropriate for the diagnosis and condition of the member at this time. The member can remain in the current acute care location until such time no further acute level care is needed. A discharge to a lower level of care would not be appropriate if the member has ongoing acute care needs. However, when the member is medically stable and no longer requires an acute level of care, the member's ongoing needs for skilled therapy, respiratory therapy, and skilled nursing may be completed in a lower level of care such as an inpatient rehabilitation facility or even a skilled nursing facility if the member's medical and therapy needs are not complex.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found that based on the provided documentation, the enrollee appears to have improved but requires additional short-term acute care services to complete treatment and determine longer-term solutions. The enrollee does not require services at the LTACH that are not already available and being received at the current facility. Therefore, LTACH services are not considered medically necessary at this time. Transfer to a lower level of care may be considered when treatment is completed, and the enrollee is more stable.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve COOLIEF radiofrequency ablation (RFA).
You asked the Plan to pre-approve COOLIEF RFA. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have 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 COOLIEF RFA. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found Cooled RFA is considered experimental/ investigational by CMS. RFA of the SI joint innervation is considered experimental/ investigational because of the wide variation in efficacy as published in the peer review literature. Therefore, the request is deemed 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 COOLIEF RFA have not been met. Therefore, we decided that the Plan does not have to pre-approve COOLIEF radiofrequency ablation (RFA).
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 disagree with the denial. The Plan denied your request. The Plan says the services are 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 in the Medicare rules section. 

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 medically necessary. Our physician reviewer found the enrollee was admitted to the hospital for right sided weakness and was treated for hyperglycemia. He is now medically stable with no complex nursing or rehabilitation needs. He does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. He requires physical and occupational therapy but there is no documented need for an intensive rehabilitation program. There is not a reasonable expectation that the 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-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 for the telephone (audio-only) consultation provided on
February 2, 2021 billed with code 99214-UD.

You asked the Plan to pay for the telephone consultation as billed. You say that this is the correct billing
method for Arizona Medicaid. The Plan denied your request. The Plan says Medicare does not allow the use of
the Place of Service code 12 to report telehealth services.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.

We find that CPT code 99214-UD is not appropriate to report the rendered services. Specifically, Medicare has
established three telephone evaluation and management (EM) codes for this purpose, 99441, 99442, and 99443.
Modifier -UD is not recognized by Medicare to indicate a telephone EM service. Based on this information, we
decided that Medicare rules for coverage of the telephone consultation as billed have not been met.

Therefore, we decided that the Plan does not have to pay for the telephone (audio-only) consultation provided on February 2, 2021 billed with code 99214-UD.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital services for the enrollee.
You asked the Plan to pay for inpatient hospital services. You say that these services are medically necessary.
The Plan denied your request. The Plan says that there is no documentation provided to support the expectation
the enrollee will require a greater than 2 midnight stay.
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 inpatient hospital services. Our reviewer
says that inpatient hospital services are not medically reasonable and necessary for the enrollee. The enrollee is
medically stable and has been provided medical clearance to undergo a total knee arthroplasty. The planned
procedure listed under CPT code 27447 is not listed on the CMS Inpatient Only List. The procedure is currently approved as an ambulatory procedure. There is no documentation provided to support the expectation
the enrollee will require a greater than a 2 midnight stay. Our physician reviewer found that the enrollee's
condition does not meet Medicare criteria for inpatient hospital 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 inpatient hospital services have not been met. Therefore, we decided that the
Plan does not have to pay for inpatient hospital services for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the requested LTACH admission is necessary. The Plan denied your request. The Plan says criteria for LTACH admission are not met.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the medical record does not indicate that the enrollee requires services that he is not currently receiving, but that would be available at the LTACH facility. The elements of the coverage rules are not satisfied. The requested service cannot be recommended.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from
May 11, 2021, through May 12, 2021.
You asked the Plan to pay for acute inpatient hospital care. You say that the hospital stay was medically necessary. The Plan denied your request. The Plan says based on Medicare guidelines, the service(s) you and/or your provider are requesting do not meet the requirements for approval.
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 that you have a history of end stage renal disease on hemodialysis and while you were at hemodialysis on May 11, 2021 you were noted to have low blood counts. You did not have any bleeding and you were able to finish the dialysis treatment and you were referred to the emergency room. In the emergency room, you had normal vital signs including oxygen levels. The hospital physician noted the plan to "admit to observation" for blood transfusion and "anticipate discharge early am". You received 2 units of blood overnight, your vital signs remained stable, you had repeat blood work which showed improved blood counts, and you were discharged home. The review has determined that the medical record did not show that at the time of the inpatient admission that the admitting physician reasonably expected that your necessary hospital care (including earlier 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 not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided from May 11, 2021, through
May 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve implants, custom fabricated abutment, bone replacement graft, and guided tissue regeneration for teeth #20, 22, 27, and 29.
You asked the Plan to pre-approve implants, custom fabricated abutment, bone replacement graft, and guided tissue regeneration for teeth #20, 22, 27, and 29. You say that the services are necessary. The Plan denied your request. The Plan says the requested services are not a covered benefit.
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 pre-approve implants, custom fabricated abutment, bone replacement graft, and guided tissue regeneration for teeth #20, 22, 27, and 29.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the SelectMDx testing provided on December 10, 2019.

You asked the Plan to pay for the testing services. You say that the test distinguishes those at increased risk for clinically significant prostate cancer. The Plan denied your request. The Plan says the test is investigational and not medically necessary.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. 

We looked at the file and the rules. The records show that the testing was used to predict the likelihood the enrollee may get prostate cancer. The records do not show how the results of the testing would change the physician's treatment strategy. This testing was requested for screening purposes. Medicare does not cover this test for screening purposes. Therefore, we decided that the Plan does not have to pay for the SelectMDx testing provided on December 10, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve AlloSure Kidney testing.
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 the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that AlloSure testing is covered when specific criteria are met. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the submitted records do not contain any objective evidence suggestive of rejection of the kidney transplant to justify AlloSure. If there is no clinical evidence of rejection, Pathology showed no evidence of T cell or antibody-mediated rejection. AlloSure is not likely to change the outcome in this setting. Therefore, the AlloSure testing 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve AlloSure Kidney testing.