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

We decided that the Plan does not have to pre-approve Otezla.
You asked the Plan to pre-approve Otezla. You say that you would like the plan to reconsider their denial The Plan denied your request. The Plan says the requested drug is not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Otezla.
Benefits for Otezla may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: 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 this is medically necessary. The Plan denied your request. The Plan says you could be treated 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 above. 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 complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care in an IRF currently. Your medical condition is not stabilized. While may benefit from physical and occupational therapy, the documentation does not indicate that you requires this therapy or can tolerate this therapy on an intensive level in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: 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 medical records provided support the need for IRF care. You say that the enrollee's required services cannot be met at home or at a lower level of care.The Plan denied your request. The Plan says IRF care is not medically reasonable and 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 above.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 complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's medical status does not require intensive physician or nursing supervision only in an IRF. The enrollee may benefit from physical therapy and occupational therapy, but the documentation does not indicate that the enrollee's functional level requires this on an intensive level in an IRF.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.
You asked the Plan to pay for the ambulance services. You say that no ambulance was requested so you should not have to pay. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on November 27, 2019. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe diagnostic colonoscopy provided on December 5, 2019.You asked the Plan to waive the copayment forthe diagnostic colonoscopy. You say that no polyps were discovered or removed. You say that a routine procedure should cost less than you were charged.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). Your contract with the Plan clearly says that you must pay a $430 copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital, including but notlimited to hospital or other facility charges and physician or surgical charges.You have been asked to pay a $430 copayment for the diagnostic colonoscopy. The diagnostic colonoscopy falls within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" benefit category. The records show that the colonoscopy was ordered for diagnostic purposes. 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 forthe diagnostic colonoscopy provided on December 5, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Lantus.
You asked the Plan to pre-approve Lantus. You say that the drug being requested is medically necessary. The Plan denied your request. The Plan says the request is not a covered benefit under your Medicare Part B plan because Lantus is a drug you give to yourself and cannot be used in an insulin pump.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Lantus.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lumbar decompression and fusion revision surgery.
You asked the Plan to pre-approve the requested spinal surgery. You say that this surgery is necessary. The Plan denied your request. The Plan says there are no indications in the record to support the need for revision at this time.
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 requested spinal surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation of a recent trial pf PT for back pain. There is no documented spinal instability, fracture, or lesion. The imaging does not show severe neural compression. Surgery is not needed 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 requested spinal surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve a lumbar decompression and fusion revision surgery.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share forthe laboratory test and electrophysiologic evaluation provided on October 16, 2019 and October 17, 2019.You asked the Plan to waive the cost share forthe electrophysiologic evaluation and laboratory test. You say that the catheter insertion was a necessary part of the operation. You say that you cannot pay the bill.The Plan denied your request. The Plan says the cost share 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). Your contract with the Plan clearly says that you must pay a $2 copayment for in-network, Medicare-covered lab servicesand 20% coinsurance for in-network, Medicare-covered surgery or other services provided to you at an outpatient hospital, including but not limited to hospital or other facility charges and physician or surgical charges. You have been asked to pay a $2 copayment for the laboratory test.You have also been asked to pay $2,497.09, which is less than the standard 20% coinsurance forthe electrophysiologic evaluation because you met your maximum out-of-pocket. The laboratory test falls within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" benefit category. The electrophysiologic evaluationfalls within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" 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 cost share forthe laboratory test and electrophysiologic evaluation provided on October 16,2019 and October 17, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea computed tomography (CT) scan of the neck.You asked the Plan to pre-approvethese 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. Medicare rules say that CT scans are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan wascorrect 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 reports ongoing pain and swelling along his clavicle with pain into the trapezius. He had plain film imaging and partial magnetic resonance imaging (MRI) that was discontinued due to anxiety. Results of these studies were not submitted for review. A physical examination notes normal palpation of neck muscles without any masses or lesions. There is no discussion of differential diagnosis from the provider ordering the computed tomography scan. The documentation does not support that the CT scan is reasonable or medically 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 these services have not been met.Therefore, we decided that the Plan does not have to pre-approvea computed tomography (CT) scan of the neck.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient surgery provided on December 19, 2019.
You asked the Plan to waive the copayment for outpatient surgery. You say that this service was provided at an office and not at the main hospital location. The Plan denied your request. The Plan says the copayment amount you are being charged is correct.
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 $100 copayment for outpatient surgery provided at a Tier 1 outpatient hospital provider. The servicing provider is considered to be an outpatient hospital facility; therefore, the outpatient hospital surgery copayment applies to this claim. You have been asked to pay $100 copayment for outpatient surgery. Outpatient surgery falls within the Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers 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 outpatient surgery provided on December 19, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Repatha Sureclick. You asked the Plan to pre-approve Repatha. You say that the enrollee has used it in the past and it worked well to manage her hyperlipidemia. The Plan denied your request. The Plan says the enrollee's medical plan does not cover outpatient prescription drugs. The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Repatha Sureclick.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecompression stockings identified with code A6530.You asked the Plan to pre-approvethe compression stockings. You say that you require these stockings for tired, achy feet and swollen ankles.The Plan denied your request. The Plan says the stockings are examples of wound care items which are non-covered under the surgical dressing benefit because they donot meet the statutory definition of a dressing.The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are noncovered because they do not meet the statutory definition of a surgical dressing. Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan.Therefore, we decided that the Plan does not have to pre-approvecompression stockings identified with code A6530.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services for the enrollee.
You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says that the enrollee was discharged after meeting short term goals and maximizing function.
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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for continued SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on December 2, 2019.
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when the patient's medical record contains sufficient documentation of the patient's medical condition to substantiate the necessity for the type and quantity of items ordered and for the frequency of use. The record shows that documentation submitted did not indicate the provider discussed the need for the billed supply code, so the billed supply code cannot be verified. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on December 2, 2019.
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. The Plan denied your request. The Plan says coverage criteria have not been met.
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 physician reviewer found that LTACHs are certified as acute care hospitals, and in general, LTACHs do not provide clinical services that are materially different than those of short term acute care hospitals. In this case, ongoing care needs include telemetry monitoring, respiratory monitoring, intravenous antibiotics, surveillance laboratory studies, indicated transfusion, wound vacuum care, and therapy services. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. 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.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
You asked the Plan to pre-approve continued services. You say that the enrollee needs an x-ray of her hip. The Plan denied your request. The Plan says the enrollee is no longer making material functional gain.
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. Continued services beyond May 1, 2020, were 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 continued services. Our physician reviewer found that the enrollee is at minimal assist with chair mobility, standby assist with bed mobility, dependent for toilet transfers and lower body dressing. This enrollee does not require skilled nursing services to safely and effectively provide medically necessary and reasonable treatment. She does not have complex wound care or other SNF level skilled nursing need. The enrollee's current functional status with weight bearing restrictions does not require skilled therapy services of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment in a SNF. The skilled nursing or skilled therapy services (or a combination of these services) are not needed on a daily basis in a SNF. As a practical matter this enrollee does not require the necessary services on an inpatient basis, in a skilled nursing facility setting.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gardasil for the enrollee.
You asked the Plan to pre-approve Gardasil. You say that this is medically necessary. The Plan denied your request. The Plan says that current medical literature and practice indicates CIN1 should be managed by surgical excision and/or monitoring only.
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 Gardasil. Our reviewer says that Gardasil is not medically reasonable and necessary for the enrollee in this case. Review of compendia notes the requested drug is FDA recommended for individuals ages 9 through 45 years. Literature does not support the use for C1N1 stage. Without the support of the literature, medical necessity cannot be determined. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for Gardasil. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Gardasil have not been met. Therefore, we decided that the Plan does not have to pre-approve Gardasil for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Trilogy home ventilator for the enrollee.
You asked the Plan to pre-approve a Trilogy home ventilator. You say that this is medically necessary. The Plan denied your request. The Plan says that the enrollee does not meet medical necessity criteria.
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. 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 Trilogy home ventilator. Our reviewer says that aa Trilogy home ventilator is not medically reasonable and necessary for the enrollee in this case. The enrollee is noted to have obesity hypoventilation syndrome. She was recently admitted with shortness of breath and pneumonia and subsequently admitted with pulmonary emboli. It appears that the enrollee was treated with BiPAP, discharged on oxygen, and then eventually treated with BiPAP and/or Trilogy. There is no evidence that the enrollee has a neuromuscular disease. There is no evidence that the enrollee has used and failed home BiPAP/CPAP. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for a Trilogy home ventilator. 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 Trilogy home ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a Trilogy home ventilator for the enrollee.