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

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care beyond August 6, 
2020. 
 
You asked the Plan to pre-approve the continued SNF care. The Plan denied your request. The Plan says 
continued SNF care is not medically necessary. 
 
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 continued SNF care. Our reviewer 
says that daily skilled services are not necessary. Our physician reviewer found that the enrollee does not 
require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional 
nurse required to safely and effectively provide medically necessary and reasonable treatment in a SNF beyond 
the last covered date. She does not have complex wound care or other ongoing SNF needs beyond the last 
covered date. She does not require skilled therapy services with the specialized skill, knowledge and judgment 
of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment in a SNF 
beyond the last covered date. She does not require skilled nursing or skilled therapy services (or a combination 
of these services) on a "daily basis" beyond the last covered date. As a practical matter,  the enrollee does not 
require the necessary services on an inpatient basis, in a skilled nursing facility setting beyond the last covered 
date. 
 
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 continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve skilled nursing facility (SNF) care beyond August 6, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve CardioMEMS. 
 
You asked the Plan to pre-approve CardioMEMS. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the requested services are not medically necessary. 
 
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 CardioMEMS. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found you have NYSHA Class III congestive heart failure with low normal LV ejection fraction 
(LVEF 30-40%) requiring hospitalization. In this circumstance, therapy change based on data obtained from a 
CardioMEMS device has been demonstrated in only one 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. Therefore, you 
do not 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 CardioMEMS have not been met. Therefore, we decided that the Plan does not 
have to pre-approve CardioMEMS.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Avastin. 
 
You asked the Plan to pre-approve Avastin. The Plan denied your request. The Plan says Avastin to be used in 
combination with Lonsurf is not supported. 
 
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 Avastin. Our physician reviewer found 
that the requested use of Avastin is not FDA-approved for your diagnosis. The requested use is not approved in 
combination with Lonsurf or after progressing twice while on Avastin. The requested use is supported by one 
of the major drug compendia or by clinical research that appears in a CMS-approved medical journal for first 
and second line combination, but only for phase 1/2 data for heavily pre-treated patients. The documentation 
does not support that the requested use of Avastin is safe and effective, and otherwise 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 Avastin have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Avastin.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued inpatient mental health services. 
 
You asked the Plan to pre-approve continued services. The Plan denied your request. The Plan says the enrollee 
does not have acute symptoms that require 24-hour care. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
Continued inpatient care beyond August 3, 2020 was requested for 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 continued services. Our physician reviewer found that active 
treatment was not taking place. The services were not reasonably expected to improve the enrollee's condition, 
or for the purpose of diagnosis. There is no individualized treatment plan provided. It did appear that the 
records were supervised and evaluated by a physician. Based upon review the records, the enrollee was not 
shown to be a danger to herself or others. She was not showing any auditory or visual hallucinations and was 
cooperative/compliant with treatment. Therefore, continued services are 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 continued services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve continued inpatient mental health services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on March 16, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require prior authorization. 
 
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 did not pre-approve the 
physician's services. We found no exception that would require the Plan to pay for these services. Therefore, 
we decided that the Plan does not have to pay for physician's services provided on March 16, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services provided on January 14, 2020. 
 
You asked the Plan to pay for the physical therapy services. The Plan denied your request. The Plan says you 
must receive care from in-network providers with the exception of emergency or urgent care, dialysis while 
temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which 
requires prior authorization from the plan.  
 
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 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 for physical therapy services provided on January 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient visit (99203) provided on February 28, 2019. 
 
You asked the Plan to pay for the outpatient visit. You say that you would like reconsideration because the 
original claim was submitted with an incorrect Member ID number. The Plan denied your request. The Plan 
says the timely filing requirements for all claim submission for an out-of-network provider is 12 months from 
the date of service. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the outpatient visit was not filed until May 4, 2020. This means that more 
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that 
the Plan does not have to pay for the outpatient visit (99203) provided on February 28, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the Part B injection provided on April 9, 
2020. 
 
You asked the Plan to waive the coinsurance for the Part B injection. You say that you were told the drug 
would be sent to the doctor's office and you were instructed how to administer it. You say you were told there 
would be no charge for the medication. 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 Medicare-covered Part B drugs and other Medicare covered items.  
 
You have been asked to pay $376.54 which is 20% of the allowed amount for the Part B injection. The allowed 
amount is $1,882.72. ($1,882.72 x 20% = $376.54). The Part B injection falls 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 injection 
provided on April 9, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care, evaluation and management of the critically ill 
or critically injured patient; first 30-74 minutes (99291) provided to the enrollee on November 14, 2019. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says the medical records do not support this service. 
 
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 99291 is not supported in the medical record. Specifically, the documentation submitted 
does not include a critical care progress note for the billed date of service of November 14, 2019; therefore, the 
billed service cannot be verified. It is noted that multiple attempts were made to contact the provider for 
additional information. 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 critical care, evaluation and 
management of the critically ill or critically injured patient; first 30-74 minutes (99291) provided to the 
enrollee on November 14, 2019.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hyalgan. 
 
You asked the Plan to pre-approve Hyalgan. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the requested drug is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that Hyalgan 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 Hyalgan. Our reviewer says that the 
documentation does not support that the requested drug is medically reasonable or necessary. Our physician 
reviewer found the enrollee has osteoarthritis of the hips. The enrollee received Hyalgan injections of both hips 
in January 2020. The only listed Part B covered diagnoses are osteoarthritis of the knee or shoulder. All other 
uses are considered investigational. Therefore, you do not meet criteria for the requested injections.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Hyalgan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Hyalgan.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve continued services. The Plan denied your request. The Plan says the 
enrollee's care appears to be custodial in nature. 
 
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. 
 
Continued SNF care beyond August 10, 2020 was requested for 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 continued services. Our physician reviewer found that the enrollee 
demonstrates severe cognitive communication impairment impacting ability to follow directions and safety 
awareness. She is at maximum assist with bed mobility and transfers. The enrollee does not require services of 
a skilled professional nurse required to safely and effectively provide medically necessary treatment in a SNF 
beyond the last covered date. She does not have complex wound care or other ongoing skilled nursing SNF 
needs beyond the last covered date. Her functional level not require therapy services of a qualified therapist to 
safely and effectively provide medically necessary treatment in a SNF beyond the last covered date. She does 
not require skilled nursing or skilled therapy services (or a combination of these services) on a daily basis. As a 
practical matter, this enrollee does not require the necessary services on an inpatient basis, in a skilled nursing 
facility setting beyond the last covered date. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on April 8, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says your Plan 
requires you to obtain care from in-network providers unless the services are emergent or urgent. 
 
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 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 for physician's services provided on April 8, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room visit provided on 
January 29, 2020. 
 
You asked the Plan to waive the copayment for the emergency room visit. You say that that paying this bill is a 
financial burden. 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 a $90 
copayment per emergency room visit within or outside the service area.  
 
You have been asked to pay a $90 copayment for the emergency room visit. The emergency room visit falls 
within the Emergency 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 waive the copayment for the 
emergency room visit provided on January 29, 2020.
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. The Plan denied your request. The Plan says the 
enrollee is receiving appropriate care at the current acute care facility. 
 
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 physician 
reviewer found that the enrollee is currently undergoing treatment at an acute care hospital (ACH) for CoViD-
19. You were intubated/ventilated and subsequently received a tracheotomy. You have since been weaned from 
the ventilator. There is no evidence that you require services that are not currently available. As LTACHs and 
ACHs are licensed to provide the same level of care, there is no advantage in transferring to the LTACH. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panel rendered on February 21, 2020. 
 
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 claim was not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that the panel must be billed with procedure 
code 81479. 
 
The file shows that the panel was not billed with code 81479 but as a panel of codes. 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 pay for the panel rendered on February 21, 2020.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve a total ankle replacement (27702). 
 
You asked the Plan to pre-approve a total ankle replacement. You say that this is medically necessary. The Plan 
denied your request. The Plan says that this is experimental. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 a total ankle replacement. Our reviewer 
says that the requested services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has history of chronic left ankle pain and weakness. Functional limitations are 
noted in activities of daily living. Clinical exam findings are consistent with severe tibiotalar degenerative 
changes, including medial deviation of the talus with associated narrowing of the medial clear space. There are 
also talonavicular and subtalar degenerative changes. Current evidence based medical literature supports total 
ankle arthroplasty as an option in this enrollee' clinical scenario as safe and effective. Given his reported active 
lifestyle (with low demand) and to maintain mobility, this request for total ankle replacement 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 a total ankle replacement have been met. Therefore, we decided that the Plan 
has to pre-approve a total ankle replacement (27702).  
 
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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Cardaic Computed Tomography (CT) with Calcium 
Scoring (75571). 
 
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 the enrollee has no active symptoms and this procedure is not covered for 
screening. 
 
The Plan follows Medicare rules. Medicare rules say that Cardiac Computed Tomography with Calcium 
scoring is not covered as a screening test. 
 
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 in this setting screening cardiac CT scanning 
with calcium scoring is not recommended and has not been shown to improve cardiac outcome incremental to 
that achievable based on treatment guided by standard clinical risk profiling and basic lipid analysis alone. 
 
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 Cardaic Computed Tomography (CT) with Calcium Scoring (75571).