Persius/hicric huggingface dataset:
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 this is medically necessary.The Plan denied your request. The Plan says the information submitted was insufficient to establish medical necessity.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 patient is currently undergoing treatment at an acute care hospital (ACH) following a cardiac arrest attributed to non-compliance with her hemodialysis. The enrollee was intubated/ventilated upon presentation and subsequently received a tracheotomy. The enrollee remains on a ventilator. There is no documentation of a neurologic assessment or attempted ventilator weaning. The enrollee's long-term prognosis is unclear. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care 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 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgicalassistant servicesprovided on June 26, 2019.You asked the Plan to pay for the surgical assistant services. You say that the provider had no choice because the surgical assistant was chosen by the operating surgeon, completely at the surgeon's discretion. The Plan denied your request. The Plan says an LSA is not covered under MedicareThe Planmust follow Medicare rules. Medicare rules say that Medicare pays for a surgical assistant when the procedure is authorized for an assistant and the person performing the service is a physician, physician assistant (PA), nurse practitioner (NP) or a clinical nurse specialist (CNS).We looked at the file and Medicare rules.The file shows that the assistant surgeon is an LSA. Medicare pays for a surgical assistant when the procedure is authorized for an assistant and the person performing the service is a physician, physician assistant (PA), nurse practitioner (NP) or a clinical nurse specialist (CNS). Based on this information, we decided that Medicare rules for coverage of the surgical assistant services have not been met. Therefore, we decided that the Plan does not have to pay for surgical assistant servicesprovided on June 26, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 3 power wheelchair and accessories.
You asked the Plan to pre-approve a Group 3 power wheelchair and accessories. You say that a Group 3 power wheelchair and accessories is medically necessary. The Plan denied your request. The Plan says durable medical equipment is not covered in a skilled nursing facility.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate and needed for use inside the home. Medicare does not consider a SNF to be a home. Records show that a Group 3 power wheelchair and accessories is being requested for use in a SNF. Therefore, we decided that the Plan does not have to pre-approve a Group 3 power wheelchair and accessories.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete series of intraoral x-rays provided on October 22, 2019.You asked the Plan to pay for the complete series of intraoral x-rays. You say that you had a set of bitewings that are covered under the Plan. You also say that the dentist's panoramic x-ray machine was down at the time of your visit.The Plan denied your request. The Plan says this service is 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 pay for the complete series of intraoral x-rays provided on October 22, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health services from an out-of-network provider.
You asked the Plan to pre-approve these services. You say that you need the services to improve mobility and overall strength. The Plan denied your request. The Plan says the services are available from network providers.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve home health services from an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the root canal (D3310) and the core build up (D2950) provided on June 26, 2019 by the out of network dentist.
You asked the Plan to reimburse you for the dental services. You say that the provider you initially saw was not able to do a root canal, so you were sent to another dentist in the same building. You say that you did not know the new dentist was not in plan. The Plan denied your request. The Plan says dental services that you receive out of network are not covered. The Plan also says that the provider in this case is not a network provider.
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, dental services that you receive out of network are not covered. Therefore, we decided that the Plan does not have to reimburse you for the root canal (D3310) and the core build up (D2950) provided on June 26, 2019 by the out of network dentist.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe ambulance transport provided on October 3, 2019.You asked the Plan to waive the copayment forthe ambulance transport. You say that you have never had a copayment. You say that you shouldn't have to pay.The Plan denied your request. The Plan says the copayment applied correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $100 copayment for Medicare-covered one-way ambulance benefit.You have been asked to pay a $100 copayment for the ambulance transport. The ambulance transport falls within the "Ambulance services" benefit category. The records show that you were transported by ambulance to the hospital. 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 forthe ambulance transport provided on October 3, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a battery pack.You asked the Plan to pre-approve a battery pack. You say that you need this to use your CPAP device at night.The Plan denied your request. The Plan says that you have a generator to power your CPAP.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured.Therefore, we decided that the Plan does not have to pre-approve a battery pack.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe first intraoral periapical x-ray and endodontic therapy provided on September 21, 2019.You asked the Plan to pay forthe first intraoral periapical x-ray and endodontic therapy. You say that this provider told you he did not participate with your Plan. You also say that this provider informed you that the Plan would reimburse you for all or part of the procedure.The Plan denied your request. The Plan says you received services from an out-of-network provider.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 covered when they are received out-of-network.Therefore, we decided that the Plan does not have to pay forthe first intraoral periapical x-ray and endodontic therapy provided on September 21, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Palonosetron, Abraxane, Keytruda, and Cinvanti for B. Weiland.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. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. The rules say that Abraxane is covered when specific criteria are met.We asked our physician reviewer to carefully review the case file and apply the relevant Medicarerules 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 enrollee has a diagnosis of stage IV metastatic undifferentiated non-small cell lung cancer (NSCLC). PD-L1 and NGS analyses are not available due to scant tumor sampling. A regimen of Keytruda and Abraxane for the treatment of Stage 4 metastatic undifferentiated non-small cell lung cancer with unknown PD-L1 and NGSstatus is not an accepted therapy that is medically reasonable and necessary and expected to be safe and effective, based on the compendia and medical literature. Since this highly emetogenic regimen is not approved, Palonosetron and Cinvanti are not 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 these services have not been met.Therefore, we decided that the Plan does not have to pre-approvePalonosetron, Abraxane, Keytruda, and Cinvanti for B. Weiland.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute IRF admission and services.You asked the Plan to pre-approveIRF care. The Plan denied your request. The Plan says the enrollee does not require frequent rehab physician assessment, or require an inpatient level of care at this time.The Plan must follow Medicare rules. The rules say that IRF admission iscovered 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 physician reviewer found that the enrollee's medical conditions appear stable. There is no complex wound care needs. There are no unaddressed medical issues. She does not require medical oversight of her condition at an acute hospital level of care. She requires physical therapy for mobility and occupational therapy for remaining activities of daily living and adaptive equipment. However, she is ambulating near household distances with minimal assistance and does not require an intensive therapy program. The enrollee is limited by debility and the severity of her comorbid medical conditions. She would not be expected to be able to fully participate in or benefit from the required intensity of an acute rehabilitation therapy program.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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that the LTACH services are medically necessary.The Plan denied your request. The Plan says the enrollee does not meet criteria for the LTACH services.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 although ongoing acute care needs are clear, transfer for equal treatment in adifferent facility would be unsafe and not productive. There were no noted treatments or services needed which would only be available at the proposed LTACH. The current treatment facility is providing appropriate care, which is covered, and should be continued. Therefore, this request for LTACH transfer will be considered 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 the LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) 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 the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.
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 admission to an IRF does not meet criteria. Our physician reviewer found the enrollee was admitted on 3/2/20 with a diagnosis of a stroke with ataxia and MRI revealing acute left occipital, medical temporal and posterior thalamus infarcts likely embolic, atrial fibrillation, flu, community acquired pneumonia and generalized weakness and was discharged on 3/5/20. He was noted to have mild confusion and cognitive deficits and mild right sided weakness with impaired balance. Based on review of the available records, the enrollee does not meet criteria for IRF admission. He may benefit from further physical therapy and occupational therapy but does not require an intensive therapy program. IRF admission is not medically necessary based on his current functional status and endurance. 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approveadditional routine transportation.You asked the Plan to pre-approveadditional routine transportation. You say that you would like the Plan to reconsider their denial.The Plan denied your request. The Plan says you are covered for up to 60 one-way trips per calendar year. The plan states you have used 56 of the 60 one-way trips for the 2020 benefit year and additional trips cannot be approved.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 60 one-way transportation trips per year. We looked at your request, the records in the case file, and the rules. The file shows you have used 56 one-way trips this year. Your contract only covers 60 one-way trips for the 2020 benefit year. This means you have 4 trips remaining and you will have exhausted this benefit for the year.Therefore, we decided that the Plan does not have to pre-approveadditional routine transportation.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an admission for skilled nursing facility (SNF) services.You asked the Plan to pre-approve the SNF services. You say that your mother has short term memory issues and she can't take of herself and she doesn't bathe. You say that you work all day and your mother can't go upstairs by herself. You say that putting your mother in therapy will allow her the opportunity to walk and have help walking as she is very unsteady on her feet. The Plan denied your request. The Plan says the enrollee does not meet Medicare criteria for SNF care.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that on February 27, 2020 the enrollee walked 120 feet with a walker with wheels and minimal assist/contact guard. Our physician reviewer found that the specialized skill, knowledge and judgment of a skilled professional nurse is not required to safely and effectively provide medically necessary and reasonable treatment. Although there are identifiable skilled therapy service needs, skilled nursing or skilled therapy services (or a combination of these services) was not medically necessary on a "daily basis" in a SNF. As a practical matter, the enrollee does not require the necessary services on an inpatient basis, in a skilled nursing facility setting.While the enrollee may benefit from continued physical therapy and occupational therapy, the documentation does not support the need for daily therapy on an inpatient basis in an SNF.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve an admission for skilled nursing facility(SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the physician services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the physician services. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are neither emergent nor urgent to seek out-of-network care. The Plan states there are equally qualified in-network cardio thoracic surgeons available to you that can provide the care you are requesting
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the physician services to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gemcitabine injections.You asked the Plan to pre-approve Gemcitabine injections. You say that you would like the Plan to reconsider their denial.The Plan denied your request. The Plan says Gemcitabine injections are not covered under the enrollee's Medicare Part B benefit. The Plan states theybelieve the enrollee's pharmacy benefit manager.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-approveGemcitabine injections.Benefits for Gemcitabine injectionsmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveQVAR RediHaler.You asked the Plan to pre-approveQVAR RediHaler. You say that you would like the Plan to reconsider their denial.The Plan denied your request. The Plan says QVAR RediHaler is not covered under the enrollee's Medicare Part B benefit.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-approveQVAR RediHaler.Benefits for QVAR RediHalermay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.