Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a segmental pneumatic compression device for the enrollee.
You asked the Plan to pre-approve the device. You say that the enrollee continues to experience moderate swelling and venous insufficiency in the bilateral lower extremities. The Plan denied your request. The Plan says there is no trial of conservative treatment.
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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no lymphedema of the chest, trunk, or abdomen. The enrollee does not have unique characteristics that would indicate the segmented pump over a standard pump. There is no documentation of a trial and failure of a standard pump. 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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve a segmental pneumatic compression device for the enrollee.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health visits for skilled nursing and physical therapy.

You asked the Plan to pre-approve home health services. You say that the requested services are necessary for your care. The Plan denied your request. The Plan says rules for home health services have not been met.

The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 

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 home health services. Our reviewer says that the requested services are not medically necessary in this case. Our physician reviewer found that you do not have documented ongoing skilled nursing nor skilled therapy needs. As such, the additional requested home health services are not shown to be currently medically necessary or reasonable. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan does not have to pre-approve home health visits for skilled nursing and physical therapy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for foot orthotics provided on January 19, 2021.
You asked the Plan to pay for foot orthotics. You say that the equipment is medically necessary to improve function and decrease in pain with ambulation. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pay for foot orthotics provided on January 19, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on May 21, 2020.

You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were
billed with the incorrect place of service.

The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or
other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service.

We looked at the file and Medicare rules. The documentation shows that the services in question were billed
with POS code 81. However, the records indicate that the specimen was collected in an office setting, which
would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. Based
on this information, we decided that Medicare rules for coverage of the lab services have not been met.
Therefore, we decided that the Plan does not have to pay for the lab services provided on May 21, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) services.
You asked the Plan to pre-approve an MRI. The Plan denied your request. The Plan says there is no
documentation the enrollee has tried and failed physical therapy.

The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically
necessary.

The file shows that an MRI of the lumbar spine was requested. 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 an MRI. Our physician reviewer found that the records indicate you have lumbar back
pain from degenerative disc disease and scoliosis. You have begun physical therapy. The trial of physical
therapy has not been completed. The medical records do not support that the requested service is medically
reasonable or necessary 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 an MRI have not been met. Therefore, we decided that the Plan does not have to
pre-approve magnetic resonance imaging (MRI) services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on July 28, 2020.

You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were billed with the incorrect place of service.

The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service.

We looked at the file and Medicare rules. The documentation shows that the services in question were billed with POS code 81. However, the records indicate that the specimen was collected in an office setting, which would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on July 28, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency care provided on January 10, 2021.
You asked the Plan to waive the copayment for emergency care. You say that the visit was to have stitches removed and feel that you should not be responsible for the charges. The Plan denied your request. The Plan says the claims were processed correctly, and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90 copayment for emergency care.
You have been asked to pay the allowed amount of $70.69, which is less than the $90 copayment for emergency care. Emergency care falls within the emergency care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for emergency care provided on January 10, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ilumya.

You asked the Plan to pre-approve Ilumya. The Plan denied your request. The Plan says the enrollee has not tried and failed a preferred agent.

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 Ilumya. Our physician reviewer found that in this case, the record indicates that the enrollee has plaque psoriasis. The requested drug is a new start. The record does not show that the enrollee has not tried and failed Humira, Enbrel, or Skyrizi. There is not a sufficient medical rationale why the plan's preferred agents would not be appropriate for 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 Ilumya have not been met. Therefore, we decided that the Plan does not have to pre-approve Ilumya.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda.
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. 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 these services. Our reviewer says that
the services are not medically necessary. Our physician reviewer found the enrollee has poorly-differentiated
base of tongue metastases. Keytruda is FDA-approved as first-line, single-agent treatment of metastatic or
unresectable recurrent HNSCC in patients whose tumors express PD-L1 (CPS =1), as determined by an
approved test. Off-label use is not supported by major drug compendia or the medical literature. Keytruda is
therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve Keytruda
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric services.

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. 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found that you were admitted to the hospital on June 30, 2021. Based on the records, it is not expected that you will improve in a reasonable period of time for the dates in question, as you are not showing suicidal or homicidal ideation and have no auditory or visual hallucinations. You are not showing any abnormal behaviors or symptoms requiring acute treatment. You are complaint with care. It does not appear that inpatient services are reasonably expected to improve your condition or for the purpose of diagnosis beyond the date in question.

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 inpatient psychiatric services.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pay for the pacemaker monitoring services (93293) provided on January 31, 2021 by an out of network (OON) provider.

You asked the Plan to pay for diagnostic services. You say that the enrollee was unable to seek the correct PCP to sign their orders. The provider may not be an MD that goes to the nursing homes but the services provided were medically necessary. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.

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 for the pacemaker monitoring services (93293) provided on January 31, 2021 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda (J9271), Yervoy (J9228), and Doxil (Q2050).
You asked the Plan to pre-approve Keytruda, Yervoy, and Doxil. You say that this is medically necessary.
The Plan denied your request. The Plan says these drugs are not supported fro the enrollee's diagnosis.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer
drugs if they are medically accepted as safe and effective or appropriate for the particular use.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve Keytruda, Yervoy, and Doxil. Our
reviewer says that the requirements for coverage of Keytruda, Yervoy, and Doxil have not been met. Our
physician reviewer found the requested use of Keytruda, Yervoy, and Doxil is not FDA-approved for the
enrollee's diagnosis and is not supported by one of the major drug compendia or by clinical research.
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, Yervoy, and Doxil have not been met. Therefore, we decided that the
Plan does not have to pre-approve Keytruda (J9271), Yervoy (J9228), and Doxil (Q2050).
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 an LTACH is medically necessary for this enrollee's condition and complex needs. The Plan denied your request. The Plan says criteria for admission to the LTACH have not been met. The enrollee's medical needs are being met in the current acute setting. The LTACH would add no additional services. With additional time in the current setting, clinical stability can be ensured such that the appropriate lower level of care can be determined.

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 he 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 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychiatric diagnostic evaluation provided on October 15, 2020 by an OON provider.

You asked the Plan to pay for the psychiatric diagnostic evaluation. You say that the rendering physician depends upon the hospital staff to verify eligibility and to obtain the proper authorization from the enrollee's insurance company. The Plan denied your request. The Plan says the service was rendered by a non-participating provider. The Plan also says that prior authorization was not obtained.

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 for the psychiatric diagnostic evaluation provided on October 15, 2020 by an OON provider.
Appeal type: Inpatient Hospital
Decision: Favorable

You asked the Plan to pre-approve acute inpatient hospital care. You say that the medical records provided support the need for an inpatient admission. The Plan denied your request. The Plan says that the guidelines for coverage of inpatient care have not been met. The Plan says that there is no documentation provided to support the expectation that the enrollee will require a greater than 2 midnight stay.
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 pre-approve acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for an inpatient admission are met in this case. Our physician reviewer found the enrollee presented with left shoulder pain for about 3 months. The pain radiates into the left lateral elbow and wrist and is worse at night. She notes weakness with weight bearing on the left arm. She notes the symptoms are getting worse. The symptoms are aching, shooting, weakness, and intermittent. Symptoms are aggravated by activity and relieved by rest. Exam of the left shoulder reveals some atrophy. There is posterior capsule tightness noted. Labral grind, biceps load, lift-off test, drop arm test, and empty-can tests are all positive. Range of motion is flexion 150 and abduction 140 with pain noted on flexion. Strength is 4+/5 internal rotation and 4/5 external rotation with pain. She was provided with a cortisone injection on this date. Magnetic resonance imaging (MRI) was opined to show an irreparable rotator cuff tear with documented failure of conservative treatments. The reverse left total shoulder arthroplasty was supported. She has a significant past medical history including asthma, high cholesterol, hypertension, and diabetes. These co-morbidities plausibly (in combination) significantly increase the risk of peri-operative complications. Therefore, the request for inpatient hospital admission for total shoulder arthroplasty is medically reasonable and necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pre-approve an inpatient hospital admission.
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 acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that these services are medically necessary and the best chance for the enrollee to return to their prior level of function. The Plan denied your request. The Plan says the record does not show that the enrollee will be able to complete at least 3 hours of therapy for 5 days a week. The enrollee does not appear to need a rehabilitation physician to see them at least 3 days a week to assess their health and functional status. The care required is not complex care that can only be provided in an inpatient rehabilitation setting. The necessary care can be provided at a lower level.

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 enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does require physical and occupational therapy, but there is no documented need for an intensive rehabilitation program. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Medically necessary services can be provided in a different 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.