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

We decided that the Plan does not have to pre-approve a bone marrow aspiration for spinal surgery (20939).

You asked the Plan to pre-approve this service. You say that this service is medically necessary for the enrollee. The Plan denied your request. The Plan says this service is 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 this service. Our reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our physician reviewer found that a bone marrow aspirate remains experimental. More research is needed to show safety and efficacy.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pre-approve a bone marrow aspiration for spinal surgery (20939).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Darbepoetin Alfa.

You asked the Plan to pre-approve Darbepoetin Alfa. You say that the requested Darbepoetin Alfa is medically
necessary. The Plan denied your request. The Plan says the requested Darbepoetin Alfa is not medically
necessary.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA approved
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 Darbepoetin Alfa. Our reviewer says
that the requested Darbepoetin Alfa is not medically necessary. Our physician reviewer found the enrollee is
diagnosed with myelodysplastic syndrome. Per major drug compendia, a patient's HGB needs to be less than 10
to approve the requested drug. The documentation shows that the enrollee's HGB is greater than 10. The
request 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 Darbepoetin Alfa have not been met. Therefore, we decided that the Plan does
not have to pre-approve Darbepoetin Alfa.
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 acute inpatient rehabilitation services are medically
necessary for this enrollee. The Plan denied your request. The Plan says effective care can be provided at a
skilled nursing facility (SNF) instead. This enrollee's care does not need to be administered by a rehabilitation
doctor or nurse.

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. Our
physician reviewer found that the complexity of the patient's nursing, medical and rehabilitation needs do not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient's
current medical condition does not require intensive physician or nursing supervision in an IRF. The patient
may benefit from additional physical and occupational therapy, but the documentation does not reveal that this
therapy must be only on an intensive level 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xiidra eye drops for the enrollee.

You asked the Plan to pre-approve the drops. You say that this is needed for dry eye syndrome. The Plan denied your request. The Plan says the medication falls under Part D coverage.

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 Xiidra eye drops for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a post and core in addition to crown (D2952).

You asked the Plan to pre-approve the post and core. The Plan denied your request. The Plan says this service is not covered under your benefit plan.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a post and core in addition to crown (D2952).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for an acute inpatient admission.

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 this is not medically necessary.

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 you are an 82 year old male who was admitted to the acute care hospital after an elective right total shoulder replacement for osteoarthritis. You were stable prior to and after recovery from the surgery. Based on the provided documentation, there was no clinical indication or expectation that he would require hospitalization that would cross 2 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 an acute inpatient admission.
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 a LTACH admission is medically necessary for the enrollee. The Plan denied your request. The Plan says a LTACH 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 the enrollee was admitted to the acute care hospital with respiratory failure, hypoglycemia, and acute renal injury. The enrollee did not improve with bi-level positive airway pressure (BiPAP) therapy, and intubation was required. Dialysis was started for renal failure. The enrollee was then extubated. The enrollee was alert with a stable blood pressure. Antibiotics have been discontinued. Long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not provide clinical services that are materially different than those of short term acute care hospitals. The enrollee is receiving acute hospital care, and acute care services have not been denied. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. The documentation does not support that an additional 25 days of hospitalization are reasonably expected for the enrollee in this case. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee 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-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lead wires for a TENS unit.

You asked the Plan to pay for lead wires. You say that A4557 is not inclusive to A4595 and should be reimbursed separately. The Plan denied your request. The Plan says the extra wires are not covered because they are replacement wires. Wires rarely need to be replaced within the past 12 months.

The Plan must follow Medicare rules. Medicare rules say that if a TENS unit has been purchased, the allowance includes lead wires and one month's supply of electrodes, conductive paste or gel (if needed), and batteries. Replacement of lead wires more often than every 12 months would rarely be reasonable and necessary. Since a TENS unit has been purchased in the previous 12 months and there is no separate indication that there is an unusual situation, the lead wires have been denied.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of lead wires have not been met. Therefore, we decided that the Plan does not have to pay for the lead wires for a TENS unit.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for a scleral rigid gas permeable lens.

You asked the Plan to pay for the contact lenses. You say that you would like reconsideration because this is a highly specialized type of contact lens used to correct conditions which cannot be adequately corrected with routine eyewear. The Plan denied your request. The Plan says that the request is not medically necessary in this clinical situation.

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 pay for the contact lenses. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found the lens is used to treat an ocular medical condition, and is not considered routine eye 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 contact lenses have been met. Therefore, we decided that the Plan has to pay for a scleral rigid gas permeable lens.

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: 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 admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH 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 admission to a LTACH is not medically necessary. Our physician reviewer found there is no documentation provided necessitating admission to a LTACH. 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. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.

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 pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested 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 considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found you were admitted for a thoracic fracture after a fall. Treatment is nonsurgical with bracing. Your medical problems are stable. The documentation does not support that you require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not support that you require an intensive rehabilitation therapy program. Your care needs can be met at a lower level of care.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital services provided from September 19, 
2020, to September 22, 2020. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says prior 
authorization is required prior to services rendered. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on September 14, 2020. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for inpatient hospital 
services provided from September 19, 2020, to September 22, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for outpatient hospital observation services 
received on August 9, 2020, and ambulance services and emergency care received on September 5, 2020. 
 
You asked the Plan to waive the copayments for outpatient hospital observation services, ambulance services, 
and emergency care. You say that these copayments should be waived due to duplicate procedures and failure 
to follow protocol by the provider. The Plan denied your request. The Plan says the correct copayments were 
applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $275 
copayment for outpatient hospital observation services, a $240 copayment for ambulance services, and a $90 
copayment for emergency care.  
 
You have been asked to pay a $275 copayment for outpatient hospital observation services, a $240 copayment 
for ambulance services, and a $90 copayment for emergency care. 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 
copayments for outpatient hospital observation services received on August 9, 2020, and ambulance services 
and emergency care received on September 5, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the additional copayment for the total knee replacement 
services (27447) provided October 9, 2020. 
 
You asked the Plan to waive the additional copayment for the total knee replacement services. You say that you 
were not aware of this additional charge to the outpatient hospital surgery. The Plan denied your request. The 
Plan says the copayment has processed correctly in this case. 
 
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 specialist visit for Medicare-covered services.  
 
You have been asked to pay an additional $50 copayment for the specialist visit related to the total knee 
replacement services. This service falls within the specialist visit for Medicare-covered 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 additional copayment for the total knee replacement services 
(27447) provided October 9, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan 
denied your request. The Plan says the stay 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 there is no documentation provided necessitating admission to a LTACH. 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 they are currently receiving care. There are 
no services available at the LTACH that the enrollee requires that are not available at the health care setting 
being offered by the health plan. 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 LTACH services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Formoterol fumarate powder.

You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your
request. The Plan says that this is not covered under Part B.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 Formoterol fumarate
powder.

Benefits for this drug 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 48 additional routine transportation trips.

You asked the Plan to pre-approve additional routine transportation trips. You say that you are requesting
additional routine transportation trips. The Plan denied your request. The Plan says your benefit only allows 24
trips for this service.

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.

We looked at your request, the records in the case file, and the rules. The 49th trip and beyond is not a covered
benefit. Your 2021 EOC states you have 24 one-way trips are covered per calendar year (limited to ground
transportation only). Therefore, we decided that the Plan does not have to pre-approve 48 additional routine
transportation trips.