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

We decided that the Plan has to pay for an inpatient admission for the enrollee.

You asked the Plan to pay for acute inpatient hospital care. You say that this is medically necessary. The Plan denied your request. The Plan says that care can be received at home with home care.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the review has determined that the record showed that at the time of inpatient admission the admitting physician reasonably expected that the enrollee's 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 been met. Therefore, we decided that the Plan has to pay for an inpatient admission 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Rezum procedure.

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 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has gross hematuria and hematochezia who previously underwent transurethral resection of the prostate (TURP). On cystoscopy he has bilateral large collapsing lateral lobes and moderate to large median lobe. There is no documentation of a quantification of prostate size. There is no indication whether the enrollee desires preservation of erectile and ejaculatory function. The provided documentation does not support the medical reasonableness and necessity of the Rezum procedure.

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 a Rezum procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve catheter ablation.

You asked the Plan to pre-approve a comprehensive electrophysiologic evaluation (93656) and intracardiac electrophysiologic 3-dimensional mapping (93613). You say that you need these services. The Plan denied your request. The Plan says you are enrolled in a clinical trial therefore medically necessary services are paid for by original Medicare.

The Plan must follow Medicare rules. Medicare rules say that Medicare approved clinical trials and certain procedures that are part of the clinical trials program can be covered by traditional Medicare, but they are not covered by the health plan.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a comprehensive electrophysiologic evaluation (93656) and intracardiac electrophysiologic 3-dimensional mapping (93613) have not been met. Therefore, we decided that the Plan does not have to pre-approve catheter ablation.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an exception to the 50 mile limit for routine transportation for the enrollee.

You asked the Plan to pre-approve exceptions to supplemental benefits. You say that the enrollee needs to see this specialist because he is unable to have his needs addressed locally. The Plan denied your request. The Plan says that the request exceeds the benefit limit.

Medicare does not cover routine transportation. While plans may offer supplemental transportation benefits they are not required to do so. Medicare does not provide exceptions to supplemental benefits. Therefore, we decided that the Plan does not have to pre-approve an exception to the 50 mile limit for routine transportation for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve superficial radiation therapy (SRT) of the forehead and left temple.

You asked the Plan to pre-approve the requested services. You say that the enrollee is at risk for an adverse event with a standard MOHS or frozen section procedure. The Plan denied your request. The Plan says the requested service is not medically necessary over the standard of care.

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 the requested services. Our physician reviewer found that radiation is a standard approach to the treatment of skin cancer, and is often preferred over surgery when resection is likely to result in unacceptable morbidity or cosmesis. In light of the lack of prospective data with mature follow up, as well as concerns regarding dosimetry, it is not recommended that electronic brachytherapy (EB) be utilized for non-melanomatous skin cancers, outside prospective clinical trials at this time. EB in these statements is meant to reflect surface electronic brachytherapy (EBT and SRT) in general. There is a lack of demonstration of need for SRT vs. traditional external beam radiation, and statements from the national comprehensive cancer network (NCCN) guidelines and medical societies that question its use. It would therefore not be considered furnished in accordance with accepted standards 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 the requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve superficial radiation therapy (SRT) of the forehead and left temple.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aflibercept (eylea).

You asked the Plan to pre-approve Aflibercept (eylea). 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.

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 Aflibercept (eylea). Our reviewer says that the documentation does not support that the requested drug is medically reasonable or necessary. Our physician reviewer found the enrollee received an examination that demonstrated left macular edema, confirmed with optical coherence tomography. Diagnosis was clinically significant macular edema for the left eye. Eylea would only be considered superior to the plan's recommended alternative (bevacizumab) in the case of diabetic macular edema with visual acuity worse than 20/50. There is evidence in the medical literature that Eylea is equivalent to Avastin (bevacizumab) when visual acuity is 20/50 or better, but superior with poorer central acuity. Therefore, it is not medically necessary for the enrollee to be treated with aflibercept over bevacizumab.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Aflibercept (eylea) have not been met. Therefore, we decided that the Plan does not have to pre-approve Aflibercept (eylea).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Rezum procedure.

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 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has benign prostatic hypertrophy and lower urinary tract symptoms. On examination, prostate size is is enlarged and his symptoms are worsening despite dual drug therapy. The case file indicates that the enrollee has an elevated PSA. The case file does not indicate a quantification of prostate size. There is no indication that the enrollee desires preservation of erectile and ejaculatory function. The provided documentation does not support the medical reasonableness and necessity of the requested Rezum procedure.

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 a Rezum procedure. 

Local Coverage Determination (LCD) L37808 referenced by the Plan is not valid for the mentioned state and was not used in the Maximus determination.
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 meets the criteria for LTACH care. The Plan denied your request. The Plan says the denial of authorization for LTACH care is correct.

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 enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 

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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services provided .You asked the Plan to pay forthe ambulance services. You say that you were following the COVID executive order for treatment in place.The Plan denied your request. The Plan says these services are not a covered benefit.The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.Therefore, we decided that the Plan does not have to pay forthe ambulance services provided .
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 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 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 your hospital course notable for pleural effusion, reintubation, extubation, cardioversion for aflutter, and tracheostomy and PEG tube placement. You are noted to remain on 40% BiPAP and tolerating well. There are no services available at the LTACH that you require that are not available at the health care setting being offered by the health plan. The documentation does not support that you require services at the LTACH that are not available at the acute care hospital where you are currently receiving 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 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approveCT of the chest.You asked the Plan to pre-approvethe CT. You say that you would like reconsideration because the member had a negative chest x-ray and ultrasound but still has pain.The Plan denied your request. The Plan says this service is not medically necessary.The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the CT. Our reviewer says that there was no indication for CT scan that was justified. Recent notes suggested that the members symptoms resolved with taking medication. Our physician reviewer found this request is considered 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 the CT have not been met.Therefore, we decided that the Plan does not have to pre-approveCT of the chest.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvebilateral facet injections.You asked the Plan to pre-approvebilateral facet injections. You say that the records provided support the need for the requested injection services.The Plan denied your request. The Plan says the requested injection 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 bilateral facet injections. Our reviewer says that bilateral facet injections are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has a T12 compression fracture and L4-L5 degenerative disc disease with left neuroforminal stenosis with radicular pain. Therefore, the criteria for coverage have not been met.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of bilateral facet injections have not been met.Therefore, we decided that the Plan does not have to pre-approvebilateral facet injections.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacupuncture.You asked the Plan to pre-approveacupuncture. 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 a covered benefit.The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the Plan's rules apply in this case. We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Specifically, the documentation does not support that you had chronic low back pain. Therefore, we decided that the Plan does not have to pre-approveacupuncture.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe duplex scan of the lower extremities (93926) provided  by an out of network (OON) provider.You asked the Plan to pay forthe duplex scan. You say that you assumed the facility where the patient resided had obtained prior authorization.The Plan denied your request. The Plan says they only cover out of network care in limited circumstances. This service was not urgent or pre-approved. It is the responsibility of the provider or facility to verify eligibility and obtain 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 had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay forthe duplex scan of the lower extremities (93926) provided by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forlaser eye surgery provided on September 25, 2020.You asked the Plan to waive the copayment forlaser eye surgery. You say that this was a laser procedure that was conducted in the same room where your routine eye exam was done. You say that you were already assessed a $15 copayment for the professional services and are now being billed for facility charges.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 $50 copayment for Medicare-covered surgeries performed in an ambulatory surgical center or outpatient hospital facility.You have been asked to pay a $50 copayment for the laser eye surgery. The laser eye surgery falls within the Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers benefit category. The records show the copayment is the facility charge for the laser eye surgery. 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 forlaser eye surgery provided on September 25, 2020.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay forlaboratory services provided .You asked the Plan to pay forthe laboratory services. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says that payment for this service is the responsibility of the facility.The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Specifically, the Plan has not provided sufficient information to verify why these services are not separately billable. Additionally, the documentation submitted doesnot clearly show that the member was inpatient for the surgery.Therefore, we decided that the Plan has to pay forlaboratory services provided .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 aletter.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foroutpatient hospital services provided .You asked the Plan to waive the copayment forthe outpatient hospital services. You say that you would like reconsideration because you should not owe anything to the hospital.The Plan denied your request. The Plan says this copayment was 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 $300 copayment for outpatient hospital services. You have been asked to pay a $300 copayment for the outpatient hospital services. These services fall within the outpatient hospital services 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 foroutpatient hospital services provided .