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

We decided that the Plan does not have to pay for the acute inpatient hospitalization.
You asked the Plan to pay for acute inpatient hospital care. You say that the service is medically necessary. The Plan denied your request. The Plan says the service 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 the enrollee is medically stable and has been provided medical clearance to undergo this elective procedure. The planned procedure listed under procedure code 27486 is not listed on the CMS
Inpatient Only List. The procedure is currently approved as an ambulatory procedure. There is no documentation provided to support the expectation the enrollee will require a greater than two midnight stay. 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. Specifically, medically necessary services can be provided in an observational level of care. This means the inpatient hospitalization is not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospitalization.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the ambulance transportation services provided on April 14, 2021.
You asked the Plan to waive the copay for the ambulance services. The Plan denied your request. The Plan says the claim processed 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 $225 copay per one-way trip for ambulance services. You have been asked to pay a $225 copay for the ambulance services. The services fall within the ambulance 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 copay for the ambulance transportation services provided on April 14, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung cancer screening.
You asked the Plan to pre-approve the requested LDCT scan. You say that you need this test because you are high risk from being a smoker over the years. The Plan denied your request. The Plan says their records show you are older than age 77 years.
The Plan must follow Medicare rules. The rules say that Medicare covers one annual LDCT scan for lung cancer screening for enrollees who meet all the above described criteria.
We reviewed the file and the Medicare rules. We find that the age criteria is not met. Therefore, we decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung cancer screening.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda for the enrollee.
You asked the Plan to pre-approve Keytruda. You say that this drug is medically necessary. The Plan denied
your request. The Plan says Medicare coverage criteria for Keytruda are not met. Maximus overturned the
Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for Keytruda.
The Maximus Physician Reviewer determined that Keytruda is FDA-approved for the enrollee's diagnosis. The
requested use is not listed as not indicated, not supported, or not recommended in any of the compendia.
Although discontinuing therapy at 2 years is an option, many clinicians treat until toxicity or progression for
those that are tolerating pembrolizumab well. The documentation does support that the requested drug is safe
and effective and otherwise reasonable and necessary for this enrollee.
The Plan argues that the package insert clearly states "... or up to 24 months in patients without disease
progression." The plan states that the "clinical value and effectiveness of Keytruda in the setting of treatment
beyond 24 months duration have not been demonstrated in the peer-reviewed literature." The medical records
show the enrollee is a 64-year-old man with poorly differentiated squamous cell carcinoma of the head and
neck, with extensive metastases to the liver and left cervical adenopathy. The enrollee was started on
immunotherapy with Keytruda in April of 2019 and has had stable disease for more than a year.
Our Medical Director says that the Plan is correct in this case. The FDA-approved label for Keytruda states that
the duration/timing of treatment for patients with head and neck squamous cell cancer is until disease
progression, unacceptable toxicity, or up to 24 months. We looked at this physician's review, the file, and
Medicare rules. Based on this information, we decided that Medicare rules for coverage of Keytruda have not
been met. Therefore, we decided that the Plan does not have to pre-approve Keytruda for the enrollee.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approve inpatient psychiatric hospitalization.
You asked the Plan to pre-approve inpatient psychiatric hospitalization. You say that the service is medically necessary. The Plan denied your request. The Plan says that the service is not medically necessary
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 inpatient psychiatric hospitalization. Our reviewer says that the service is medically necessary. Our physician reviewer found it does appear that active treatment is taking place beyond the date in question and that the services for the dates in question were reasonably expected or medically necessary to improve your condition or for the purpose of diagnosis. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient psychiatric hospitalization have been met. Therefore, we decided that the Plan has to pre-approve inpatient psychiatric hospitalization.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on September 2, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not approved in advance.
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 services at issue in this appeal. 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 the services provided by an out-of-network provider on September 2, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652, E0667).
You asked the Plan to pre-approve a pneumatic compression device. You say that the requested items are a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for pneumatic compression devices have not been met.
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (E0652, E0667).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy services (97110) provided on July 21, 2020.
You asked the Plan to pay for the physical therapy services. You say that you would like reconsideration
because the services rendered were medically necessary. The Plan denied your request. The Plan says there is a
more appropriate CPT code for the services rendered.
The Plan must follow Medicare rules. Medicare rules say that when therapy services are billed as incident to a
physician/NPP services, the requirement for direct supervision by the physician/NPP and other incident to
requirements must be met, even though the service is provided by a licensed therapist who may perform the
services unsupervised in other settings.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the physical therapy services have not been met. Specifically, this claim was billed by a nurse
practitioner (NP). The record does not show that the NP was present for direct supervision while these services
were being rendered. Therefore, we decided that the Plan does not have to pay for the physical therapy services
(97110) provided on July 21, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Evenity for the enrollee
You asked the Plan to pre-approve Evenity. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says that the enrollee does not have any stated contraindications to the preferred products.
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 Evenity. Our reviewer says that Evenity is not medically reasonable and necessary for the enrollee in this case. The patient has not tried and failed Tymlos or Forteo. There is no indication that the Plan's required drugs would likely be less effective and/or likely have adverse effects for the patient. Our physician reviewer found that the enrollee's condition does not meet step therapy criteria for Evenity. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Evenity have not been met. Therefore, we decided that the Plan does not have to pre-approve Evenity for the enrollee
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia injections.
You asked the Plan to pre-approve Prolia (J0897) Injection, denosumab, 1 mg. You say that the enrollee needs the injections for pain relief. The Plan denied your request. The Plan says the enrollee does not have a history of osteoporotic fracture and has not tried and failed zoledronic acid.
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 Prolia (J0897) Injection, denosumab, 1 mg. Our reviewer says that the drug is not medically reasonable and necessary. Our physician reviewer found based on the medical records provided the patient has not tried and failed the required drugs. Based on the medical records provided there is no indication that the plan's required drug would likely be less effective and/or likely have adverse effects for the patient. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia (J0897) Injection, denosumab, 1 mg have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia injections.
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 service is medically necessary. The Plan denied your request. The Plan says the service is 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 the enrollee's medical conditions are stable and there are no complex nursing or rehabilitation needs. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation 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. Specifically, medically necessary services can be obtained at a lower level of care. This means admission into an IRF is not medically necessary or reasonable. 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-approve additional routine transportation trips.
You asked the Plan to pre-approve additional routine transportation trips. You say that you need more trips for medical services. The Plan denied your request. The Plan says that this benefit is exhausted.
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 fifty (50) trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation trips.
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 service is medically necessary. The Plan denied your request. The Plan says the service 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 the enrollee appears to be more stable but is not improving significantly and requires only short-term additional acute care services which can be safely administered at the current facility. The enrollee does not require services at the LTACH that are not already available at the current facility. 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. Specifically, medically necessary services are being obtained at the enrollee's current level of care and there are no additional services that the LTACH offers that the enrollee needs.
This means admission into a LTACH is not medically necessary or reasonable. 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 the service is medically necessary. The Plan denied your request. The Plan says the service is 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 the enrollee's medical conditions are stable and there are no complex nursing or rehabilitation needs. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for a intensive, multi-disciplinary rehabilitation 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. Specifically, medically necessary services can be obtained at a lower level of care. This means admission into an IRF is not reasonable or necessary. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve enteral nutrition.
You asked the Plan to pre-approve enteral nutrition. You say that the enrollee requires this due to malnutrition. The Plan denied your request. The Plan says the requested item is not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation. The items you asked the Plan to pre-approve are considered nutritional supplements. Although these may be appropriate, neither Medicare nor the Plan provides coverage for them. Therefore, we decided that the Plan does not have to pre-approve enteral nutrition.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the inpatient hospital services provided from January 25, 2021, and January 29, 2021.
You asked the Plan to waive the copay for the services provided. You say that the claim is Coronavirus related. The Plan denied your request. The Plan says the claim processed 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 $175 copay per day for days 1-5 for inpatient hospital care. The file shows that you received 4 days of inpatient care for cellulitis. You have been asked to pay a $175 copay per day, totaling $700, for the services provided. The services fall within the inpatient hospital care benefit category. The records do not show that the services provided were related to Coronavirus. 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 copay for the inpatient hospital services provided from January 25, 2021, and January 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bioimpedance spectroscopy for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says any drug, device, treatment or procedure that is experimental, investigational or unproven is not a covered benefit.
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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the record indicates that the enrollee has breast cancer. The records provided do not indicate the enrollee has lymphedema. The provided medical records are insufficient to determine the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. There is insufficient literature to establish the requested test as safe and effective, as defined by Medicare rules, for the enrollee's specific clinical condition. The elements of the coverage criteria are not satisfied.
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 services have not been met. Therefore, we decided that the Plan does not
have to pre-approve bioimpedance spectroscopy for the enrollee.