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

We decided that the Plandoes not have to pre-approve placement of a CardioMEMS heart failure monitor.You asked the Planto pre-approvethe CardioMEMS procedure. You say that this is a proven device which would have a clear benefit for this enrollee.The Plandenied your request. The Plansaysthere is insufficient literature support for the use of this device.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 CardioMEMS procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found 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. Medicare coverage criteria are not met since the device should still be considered experimental or investigational.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 CardioMEMS procedure have not been met.Therefore, we decided that the Plandoes not haveto pre-approveplacement of a CardioMEMS heart failure monitor.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on October 3, 2019.You asked the Plan to pay forthe laboratory services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services provided are not a covered benefit.The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.The laboratory testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes.Therefore, we decided that the Plan does not have to pay forthe laboratory services provided on October 3, 2019
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve hand splints.You asked the Plan to pre-approve hand splints. You say that the claim should be covered.The Plan denied your request. The Plan says that services are not supported in the medical records received.The Plan follows Medicare rules. Medicare rules say that Medicare does not pay for any items or services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.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 hand splints. Our reviewer says that the services are medically necessary. Our physician reviewer found the enrollee has bilateral hand contractures related to rheumatoid arthritis. Activities of Daily Living are affected by the hand contractures. Physical therapy is helping reduce contracture. The requested off-the-shelf bilateral hand splints are prescribed to improve contracture/reduce risk of progression. The medical records provided do meet the requirements listed in the LCD/PIM for Medicare coverage.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of hand splints have been met.Therefore, we decided that the Plan has to pre-approvehand splints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe periodontal scaling and root planing (D4341) for the upper left and lower left quadrants provided on October 10, 2019.You asked the Plan to pay forthe dental services. You say that you were advised at the time you received the services that they would be covered.The Plan denied your request. The Plan says dental services received out of network are not covered. The Plan also says that the provider in this case is not a Plan provider.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the dental services you received are not covered when you receive them out of network.Therefore, we decided that the Plan does not have to pay forthe periodontal scaling and root planing(D4341) for the upper left and lower left quadrants provided on October 10, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider on July 10, 2019.You asked the Plan to pay for the services. You say that the services were medically necessary.The Plan denied your request. The Plan says the services were not authorized.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 has network providers available who can provide 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 forthe medical services provided to the enrollee by an out-of-network provider on July 10, 2019
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the full cost share amount forthe surgical extraction (D7210) for tooth # 19 provided on January 1, 2019.You asked the Plan to pay the full cost share amount forthe dental service. You say that you paid $130 of the $325 charge. You say that the Plan paid $79.50 but they should have paid $162.50.The Plan denied your request. The Plan says there is a 55% coinsurance for extractions rendered by an out of network provider.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverageand extractions are a covered service, there is a 55% coinsurance when you receive this service out of network. Therefore, we decided that the Plan does not have to pay the full cost share amount forthe surgical extraction (D7210) for tooth # 19 provided on January 1, 2019.
Appeal type: SNF
Decision: Unfavorable

e decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.You asked the Plan to pre-approveSNF care. You say that the services are necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are skilled nursing and therapy needs, but they do not need to be provided on a daily basis. Your care can be appropriately provided through home-based and outpatient services with intermittent scheduled services for lower body activities of daily living if needed. If stair climbing is anissue, this would most appropriately occur on the actual stairs in the home setting. Rearrangement of the living space (e.g. setting up a bed on the first floor) or use of adaptive equipment (e.g. commode) would be examples of ways in which a stair climbing deficit could be addressed.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met.Therefore, we decided that the Plan does not have topre-approveskilled nursing facility (SNF) care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that the services are medically necessary. The Plan denied your request. The Plan says the services are 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 services are not medically necessary. Our physician reviewer found the enrollee was admitted to the hospital on January 27, 2020 with suspected pneumonia with sepsis and respiratory failure. 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 she is currently receiving care. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan. 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 for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an additional level of radiofrequency ablation (64636).
You asked the Plan to pre-approve an additional level of radiofrequency ablation (64636). You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested 6 joints would exceed the allowable limit for this service.
The Plan must follow Medicare rules. Medicare rules say that no more than 4 joints are allowed to be injected per session. We looked at the file and Medicare rules. The original request was for 6 joints to be injected. Medicare covers no more than 2 thermal radiofrequency sessions in any 12-month period, involving no more than 4 joints per session, e.g., 2 bilateral levels or 4 unilateral levels. In this case, the Plan approved 2 joints at 2 levels, which is the allowed amount per session. Therefore, we decided that the Plan does not have to pre-approve an additional level of radiofrequency ablation (64636).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.
You asked the Plan to pre-approve these services. You say that you need physical therapy. The Plan denied
your request. The Plan says the admission 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 these services. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found the records show that you were admitted
to the hospital on February 4, 2020 for left knee surgery. You need assistance with bed mobility, walking with
a rolling walker, showering, and balance. You have no skilled nursing needs. You have skilled therapy needs
but do not require skilled therapy on a daily basis. As a practical matter, you do not require the necessary
services on an inpatient basis at the SNF 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 these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve a skilled nursing facility (SNF) admission.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a Skilled Nursing Facility (SNF).
You asked the Plan to pre-approve SNF admission. You say that you need to build up strength to be admitted to assisted living. The Plan denied your request. The Plan says the denial of authorization for SNF service is correct.
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 SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a Skilled Nursing Facility (SNF) setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a Skilled Nursing Facility (SNF).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone and/or joint imaging; whole body scan (78306).You asked the Plan to pre-approve bone and/or joint imaging; whole body scan. You say that the service is necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.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 bone and/or joint imaging; whole body scan. Our reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our physician reviewer found you are asymptomatic. You have no imaging findings to suggest extracapsular spread of cancer and a prostate specific antigen (PSA) of 6.1 and Gleason score of 7. As such accepted criteria are not met for radionuclide imaging.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of bone and/or joint imaging; whole body scan have not been met.Therefore, we decided that the Plan does not have to pre-approvebone and/or joint imaging; whole body scan (78306).
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approvediabetic shoes (A5500) and inserts (A5513).You asked the Plan to pre-approvediabetic shoes (A5500) and inserts (A5513). You say that you would like the plan to reconsider theirdenial.The Plan denied your request. The Plan says that they were unable to make a determination within the allotted time frame.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, theappellant's argument for the reason the enrollee needs the items provided by an out-of-network provider is that the out-of-network provider is the only facility in the enrollee's area that will go to the enrollee's home/facility. The Plan has not providedany documentation in regards to addressing why the enrollee needs a provider to come to their home and if this is medically necessary. The Plan has not documented that the Plan providers are capable of going to the enrollee's home if deemed medically necessary based on Medicare criteria.Therefore, we decided that the Plan has to pre-approvediabetic shoes (A5500) and inserts (A5513).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 webelieve 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-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that the enrollee meets LTACH admission criteria.The Plan denied your request. The Plan says the enrollee's needs are being met in the current acute care setting.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-approvethe LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found based on the provided medical records the patient is receiving necessary services and is atan appropriate level of care in the acute care hospital. Continued care at this level is appropriate until the patient is stable to transfer to a lower level of care such as an inpatient rehabilitation facility, a skilled nursing facility, sub-acute rehabilitation facility or home with home health 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 the LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Benlysta.
You asked the Plan to pre-approve Benlysta. You say that the requested drug is medically necessary. The Plan denied your request. The Plan says the enrollee's doctor did not provide documentation indicating ANA Positive greater than or equal to 1:80 or Anti-ds DNA greater than or equal to 30IU/ml. The plan says that this request does not meet the Health Care Medical Policy for Benlysta.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. 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 Benlysta. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee has a diagnosis of discoid lupus. She has been treated with Benlysta for the past 5 years with good response. The enrollee's prior treatment was not documented in the information provided to us. The documentation does support that Benlysta is safe and effective for the enrollee. The medical record documents a good response to prior treatment with Benlysta. However, the documentation does not support that Benlysta is medically reasonable and necessary for the enrollee. Benlysta is not FDA approved for use for discoid lupus. Benlysta is FDA approved for treatment of systemic lupus erythematosus with active, autoantibody-positive systemic lupus erythematosus (SLE) who are receiving standard therapy. The enrollee does not have a diagnosis of systemic lupus. There is no history of other prior treatments for discoid lupus reported. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Benlysta have not been met. Therefore, we decided that the Plan does not have to pre-approve Benlysta.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ilumya 100 mg/ml syringe.You asked the Plan to pre-approvethe Ilumya. You say that the medication is medically necessary.The Plan denied your request. The Plan says coverage rules have not been met.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 the Ilumya. Our reviewer says that the requested drug is not medically necessary. Our physician reviewer found the documentation does not support that the Ilumya is safe and effective for the patient. Ilumya is not FDA approved for use for hidradenitis suppuratva and its use for this indication is not supported in medical literature. Additionally, although the appeal states that the enrollee's condition has been hard to treat, it only describes current treatment with minocin. No other failed treatment trials are documented.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decidedthat Medicare rules for coverage of the Ilumya have not been met.Therefore, we decided that the Plan does not have to pre-approveIlumya 100 mg/ml syringe
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the UPWalker upright mobility walker purchased on August 15, 2019.
You asked the Plan to reimburse you for the UPWalker upright mobility walker. You say that the membership
book said walkers were covered so you purchased one. The Plan denied your request. The Plan says you are
approved for a standard walker but the UPWalker is not covered by Medicare or the Plan.
The Plan must follow Medicare rules. Medicare rules say that for any item to be covered by Medicare it must
meet all applicable Medicare statutory and regulatory requirements.
We looked at the file and Medicare rules. The UPWalker is not covered by Medicare or the Plan. You did not
inquire about a walker before purchasing one and you requested a physician order after the date of service.
Based on this information, we decided that Medicare rules for coverage of the UPWalker upright mobility
walker have not been met. Therefore, we decided that the Plan does not have to reimburse you for the
UPWalker upright mobility walker purchased on August 15, 2019.