Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy services.
You asked the Plan to pre-approve the physical therapy services. You say that you would like reconsideration
because you need more physical therapy. The Plan denied your request. The Plan says additional physical
therapy is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient
therapy.
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 physical therapy services. Our
reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration
of the enrollee's condition. Our physician reviewer found the records do not demonstrate that the unique skills
of a professional therapist are required to safely and effectively provide treatment, or that the services can be
safely and effectively performed only by a therapist, or under the supervision of a therapist.
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 physical therapy services have not been met. Therefore, we decided that the
Plan does not have to pre-approve physical therapy services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda.
You asked the Plan to pre-approve Keytruda. The Plan denied your request. The Plan says guidelines do not support the use of Keytruda in colon cancer unless molecular changes can be demonstrated.
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. Our physician reviewer found that Keytruda is approved for tumor mutational burden (TMB) of less than 10 mutations per megabase for those who have had previous treatment and have no other options. As this is being requested as first line therapy, the requested drug is not safe and effective and otherwise reasonable and necessary for this 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 Keytruda have not been met. Therefore, we decided that the Plan does not have to pre-approve Keytruda.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Rituxan.
You asked the Plan to pre-approve Rituxan. The Plan denied your request. The Plan says the drug is not being used along with other agents.
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 Rituxan. Our physician reviewer found that the enrollee is status post transplant for acute lymphoblastic leukemia. The requested use of the drug is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. Per Compendia there is no role for maintenance Rituxan for the enrollee's condition. The documentation does not support that the requested drug is safe and effective and otherwise reasonable and necessary for this 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 Rituxan have not been met. Therefore, we decided that the Plan does not have to pre-approve Rituxan.
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. The Plan denied your request. The Plan says that your needs can be safely met at a lower level of care.
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. You do not require the intensity of services provided at an IRF. Specifically, you are not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. Your care needs can be met at a lower level of care. Our physician reviewer found that your condition does not meet Medicare criteria for IRF 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 pre-approve a spinal fusion.
You asked the Plan to pre-approve a spinal fusion. 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. 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 a spinal fusion. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found criteria for spinal fusion is not met. There is no instability, fracture or lesion. The enrollee has degenerative discs and had L3-5 previous laminectomy. However, there is no spinal instability demonstrated. Fusion is not needed. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a spinal fusion have not been met. Therefore, we decided that the Plan does not have to pre-approve a spinal fusion.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the enrollee meets IRF criteria. The Plan denied your
request. The Plan says rules for IRF care have not been met.
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 enrollee does not require the intensity of services provided at an
IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and
regular physician evaluation.
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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a Medicare Part B drug provided on October 22, 2020.
You asked the Plan to waive the coinsurance for a Medicare Part B drug. You say that you got pre-approved for the injection and were told that you would not owe anything. 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 20% coinsurance for Medicare Part B prescription drugs. You received a Medicare Part B drug on October 22, 2020. The total allowed amount is $394.75 and 20% of that is $78.95. You have been asked to pay the total coinsurance amount of $78.95 for a Medicare Part B drug. A Medicare Part B drug falls within the Medicare Part B prescription drugs 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 coinsurance for a Medicare Part B drug provided on October 22, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a LTACH for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan
denied your request. The Plan says needs could be met in an alternate level of care.
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 improving and more stable requiring only short-term
additional acute care services to complete treatment that can be safely completed at the current facility. The
enrollee does not require services at the LTACH that are not already available at the current facility. Therefore,
this request for LTACH services will be considered not medically necessary at this time. Transfer may be
considered soon.
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 admission to a LTACH for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that the enrollee needs to be supervised due to her prior history of multiple joint dislocations. The Plan denied your request. The Plan says the enrollee does not require an intensive multidisciplinary approach to daily therapy.

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 physician reviewer found that the enrollee was at a contact guard to minimal assist level for standing up, and contact guard assist for walking. The enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. 

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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for paramedic intercept services provided on November 19, 2020.
You asked the Plan to pay for this service. You say that this service should be covered by the Plan. The Plan denied your request. The Plan says these services are not covered by Medicare.
The Plan must follow Medicare rules. The rules say that Medicare pays for advanced life support (ALS), in accordance with state and local laws by an emergency medical technician (EMT) intermediate or EMT-Paramedic only in certain circumstances. Medicare allows ALS paramedic intercept services only when the services are furnished under a contract with a qualified basic life support (BLS), the provision of medically necessary supplies and services, with a volunteer ambulance company. In addition, State law must not allow the volunteer ambulance company to bill for the transport or BLS services. The Plan has confirmed that the transport provider does not have a contract with the volunteer ambulance company that provided the transport services. Therefore, we decided that the Plan does not have to pay for paramedic intercept services provided on November 19, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health services 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 there are no skilled needs.
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 the services. Our reviewer says that the
requested services are not medically reasonable or necessary. Our physician reviewer found the records do not
show that skilled nursing services are required to effectively provide treatment, care, and/or services in order to
improve the enrollee's condition, or to establish/perform a maintenance program to maintain the enrollee's
condition and/or prevent deterioration. There is no evidence of complex wound care, IV antibiotics, new
enteral feeding or other skilled nursing need. The records do not show that skilled therapy services are required
to effectively provide treatment, care, and/or services in order to improve the enrollee's level of function, or to
establish/perform a maintenance program to maintain the enrollee's level of function and/or prevent
deterioration. The enrollee has had prior therapy with instruction on a home exercise program which he is
intermittently performing. As the enrollee does not require skilled services, the criteria are not met.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not
have to pre-approve home health services for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental services to be provided by an out of network provider.
You asked the Plan to pre-approve out of network dental services. You say that you need the dental services approved because you cannot eat and speak properly. The Plan denied your request. The Plan says this provider is not in network.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 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. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve dental services to be provided by an out of network provider.
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to reduce the cost for the test materials. We also decided that the Plan does not have to waive the cost for the test materials.
You asked the Plan to reduce the cost for the test materials. You say that you are doing this yourself and should not be charged for the services. The Plan says that the copayments applied correctly.
We decided that the Plan has to reduce the cost for the test materials.
The test materials are considered a medical supply not a physician service. The Plan contract clearly says that enrollees pay 20% coinsurance for medical supplies from an in-network provider. Therefore, we decided the Plan has to reduce the cost for the test materials from $35 for each date of service to 20% of the allowed amount for each date of service.
We also decided that the Plan does not have to waive the cost for the test materials.
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 20% coinsurance for medical supplies from an in-network provider. Therefore, we decided that the Plan does not have to waive the cost for the test materials.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the lumbar injection provided on February 24, 2020.

You asked the Plan to waive the copayment for the lumbar injection. You say that this was done at a clinic not a hospital. You say that the responsibility should be $45. The Plan denied your request. The Plan says the copayment applied correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a $250 copayment for surgery services at an in-network outpatient hospital. 

The enrollee has been asked to pay a $250 copayment for the lumbar injection. The lumbar injection falls within the "Outpatient hospital services" benefit category. The records show the injection was billed by the hospital. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the lumbar injection provided on February 24, 2020.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for infectious agent detection testing (procedure code 87631) provided on September 8, 2020.
You asked the Plan to pay for infectious agent detection testing. You say that you have no knowledge of the enrollee's coverage prior to the specimen's arrival, and request that your lab not be penalized for being out-of-network. The Plan denied your request. The Plan says that this test is not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that infectious agent detection testing code 87631 is covered when performed in places of service 20, 21, or 23 (urgent care, inpatient hospital, or emergency room settings), when ordered by an infectious disease specialist, or under certain limited exceptions. We looked at the file and Medicare rules. This testing is covered by Medicare, and the billing of this claim does meet the associated diagnosis code relationship for limited coverage of procedure code 87631. However, this testing was not performed in an urgent care, inpatient hospital, or emergency room setting. The record shows that the sample for this testing was taken in an assisted living/nursing facility. This testing was ordered by a physician with a specialty other than infectious disease. At the time of this testing the enrollee was not living in a rural location, island, or other location where access to care with an infectious disease specialist would have been limited. Based on this information, we decided that Medicare rules for coverage of infectious agent detection testing have not been met. Therefore, we decided that the Plan has to pay for infectious agent detection testing (procedure code 87631) provided on September 8, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on November 17, 2020.

You asked the Plan to pay for the laboratory services. The Plan denied your request. 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they 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 did not pre-approve the laboratory service. 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 laboratory services provided on November 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aids (V5160) received on October 13, 2020.

You asked the Plan to pay for hearing aids. You say that you would like the Plan to pay for the items. The Plan denied your request. The Plan says this is not a covered benefit.

The Plan must follow Medicare rules. The rules say that Medicare does not cover hearing aids or related services. 

Though hearing aids may be appropriate in this case, neither Medicare nor the Plan covers or pays for these types of items and services. Therefore, we decided that the Plan does not have to pay for hearing aids (V5160) received on October 13, 2020.