Persius/hicric huggingface dataset:
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 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 IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the documentation does not support that the complexity of your nursing, medical and rehabilitation needs require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation is insufficient to demonstrate that you are reasonably expected to fully participate in and benefit from the intensive rehabilitation therapy program provided 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nursing facility care provided by an out-of-network provider.

You asked the Plan to pay for nursing facility care. You say that medical records and proof of timely filing are attached for retro authorization. The Plan denied your request. The Plan says in-network providers were available.

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 nursing facility care provided by an out-of-network provider.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Keytruda (J9271).

You asked the Plan to pre-approve Keytruda. You say that the requested drug is medically necessary. The Plan denied your request. The Plan says that the use of the requested drug for the enrollee's condition is not reasonably and necessary.

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 reviewer says that the use of the requested drug is medically necessary and reasonable. Our physician reviewer found that Keytruda is not FDA-approved for the enrollee's diagnosis nor is the use supported by one of the major drug compendia. However, the use of Keytruda for the enrollee's specific condition is not listed as not indicated, not supported or not recommended in any of the compendia. Additionally, our reviewer found support for the use of Keytruda for the enrollee's specific condition in clinical research that appears in Medicare-approved medical journals. The documentation supports that the requested drug is safe and effective and otherwise reasonable and necessary 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 Keytruda have been met. Therefore, we decided that the Plan has to pre-approve Keytruda (J9271).

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: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hyalgan/Supartz and Genvisc 850 injections (J7320, J7321).

You asked the Plan to pre-approve Hyalgan/Supartz and Genvisc 850 injections. You say that you need this medication to perform daily activities. The Plan denied your request. The Plan says step therapy criteria have not been met.

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 Hyalgan/Supartz and Genvisc 850 injections. Our reviewer says that the criteria for coverage of the requested drugs have not been met. Our physician reviewer found the Plan requires a trial of Durolane, Gelsyn-3 and Synvisc/Synvisc-One before they will approve the requested drugs. In this case, the patient has not tried and failed the required drugs. There is no documentation provided indicating that the plan's required drugs likely be less effective or have adverse effects 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 Hyalgan/Supartz and Genvisc 850 injections have not been met. Therefore, we decided that the Plan does not have to pre-approve Hyalgan/Supartz and Genvisc 850 injections (J7320, J7321).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the CT scan provided on September 17, 2020.
You asked the Plan to waive the copayment for the CT scan. You say that you were told the CT scan would be covered. You say you cannot afford this amount. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing 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 $275 copayment for in-network Medicare-covered diagnostic radiology services in an outpatient hospital setting. You have been asked to pay a $275 copayment for the CT scan. The CT scan falls within the "Outpatient diagnostic tests and therapeutic services and supplies" 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 the CT scan provided on September 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a second opinion to be provided by an out of network (OON) provider at a tertiary care facility.
You asked the Plan to pre-approve a second opinion with an OON provider. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says there are in-network tertiary level of care providers that can manage and treat your condition.
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 items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a second opinion to be provided by an out of network (OON) provider at a tertiary care facility.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Nasal/Sinus endoscopy with dilation to the maxillary sinuses for the enrollee.
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the clinical value and effectiveness of a nasal/sinus endoscopy with dilation to the maxillary sinuses in the setting of a normal CT scan of the maxillary sinuses has not been demonstrated in the peer-reviewed literature.
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 these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. The literature and the guidelines from the Academy of Otolaryngology does not support the use of balloon sinuplasty when the computed tomography (CT) does not show evidence of obstruction or chronic sinusitis. This patient's CT did not show evidence of chronic sinusitis in the maxillary sinuses. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for these 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve Nasal/Sinus endoscopy with dilation to the maxillary sinuses for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 3 power wheelchair (PWC) with related accessories/components.

You asked the Plan to pre-approve the Group 3 PWC requested. You say that you require this PWC due to your lack of mobility. The Plan denied your request. The Plan says you do not meet medical necessity criteria for the requested type of PWC.

The Plan follows Medicare rules. Medicare rules say that Group 3 PWCs are covered for enrollees with mobility limitations caused by either neurological conditions, myopathies, or congenital skeletal deformities.

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 Group 3 PWC requested. Our reviewer says that the documentation does not support that the criteria for coverage of a Group 3 PWC are met. Our physician reviewer found there is no documentation of any neurological condition, myopathy, or congenital skeletal deformity for which a Group 3 PWC can be covered.

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 Group 3 PWC requested have not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 3 power wheelchair (PWC) with related accessories/components.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an orthosis and sleeve (L2397, L1833).

You asked the Plan to pay for the orthosis and sleeve. You say that the orthosis is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.

The Plan follows Medicare rules. Medicare rules say that for this type of orthosis to be covered, knee instability must be documented by examination of the beneficiary and objective description of joint laxity.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the orthosis and sleeve. Our reviewer says that the requested orthosis is not medically necessary. Our physician reviewer found there is insufficient documentation of a credible evaluation of the enrollee, and there is insufficient credible objective documentation of joint laxity.

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 orthosis and sleeve have not been met. Since the base orthosis is not covered, the sleeve is non-covered also. Therefore, we decided that the Plan does not have to pay for an orthosis and sleeve (L2397, L1833).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 3 power wheelchair with multiple power
options (K0861).
You asked the Plan to pre-approve a Group 3 power wheelchair with multiple power options. You say that the
requested items are medically necessary. The Plan denied your request. The Plan says rules for pre-approval
are not met because the requested items are not reasonable and necessary.
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 Group 3 power wheelchair with
multiple power options. Our reviewer says that the requested items are not considered medically reasonable
and necessary in this case. Our physician reviewer found that the documentation indicates the enrollee has a
mobility deficit that impairs MRADLs in the home and is not ameliorated by a walker, cane, or manual
wheelchair due to poor endurance and lack of strength. The enrollee has the cognitive ability to manage a
power wheelchair. The enrollee has a neurological condition that could qualify for a Group 3 power
wheelchair. However, the enrollee does not require a power seating system. The enrollee is able to perform an
independent weight shift, does not use intermittent catheterization for bladder management, and the
documentation does not support that the enrollee needs a power seating system is needed to manage increased
tone or spasticity.
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 Group 3 power wheelchair with multiple power options have not been met.
Therefore, we decided that the Plan does not have to pre-approve a Group 3 power wheelchair with multiple
power options (K0861).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based composite and endodontic therapy provided on March 19, 2020.
You asked the Plan to pay for the resin-based composite and endodontic therapy. You say that you would like these services to be covered. The Plan denied your request. The Plan says the claim processed correctly per your plan policy, and you are responsible for the copayment amount that applied.
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, you are responsible for a 20% coinsurance for endodontic services, and a 20% to 50% coinsurance for restorative services after you pay your $50 deductible. Therefore, we decided that the Plan does not have to pay for the resin-based composite and endodontic therapy provided on March 19, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve attendant services.
You asked the Plan to pre-approve attendant services. 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 custodial care is excluded from coverage. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of attendant services have not been met. Therefore, we decided that the Plan does not have to pre-approve attendant services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Dronabinol.
You asked the Plan to pre-approve Dronabinol. You say that the medication is necessary. The Plan denied your request. The Plan says the enrollee has a medical only policy which does not include Part D prescription coverage, therefore the criteria for self-administered drug coverage has not been met.
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 Dronabinol.
Benefits for Dronabinol 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the preventive procedure provided on December 10, 2020.
You asked the Plan to pay for the preventive procedure. You say that you would like this service to be covered. The Plan denied your request. The Plan says the preventive procedure is not a covered benefit.
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 requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the preventive procedure provided on December 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nursing facility care provided by an out-of-network provider.

You asked the Plan to pay for nursing facility care. You say that the provider depends on hospital staff to verify eligibility and obtain proper authorization. You say that the services were medically necessary, and the claim should be processed for payment. The Plan denied your request. The Plan says the plan requires the utilization of in network providers.

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 nursing facility care provided by an out-of-network provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visit provided on October 14, 2020 by an OON provider.
You asked the Plan to pay for the domiciliary or rest home visit. You say that the facility failed to obtain the necessary authorization for this enrollee. You also say that the rendering physician depends upon the hospital staff to verify eligibility and to obtain the proper authorization for in-network and out-of-network providers from the enrollee's insurance. The Plan denied your request. The Plan says the service was rendered by an OON 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 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 domiciliary or rest home visit provided on October 14, 2020 by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis (L1833) with suspension sleeve (L2397) provided to the enrollee.

You asked the Plan to pay for these items. You say that these items were medically necessary. The Plan denied your request. The Plan says that your request is not a covered benefit because your records show that your evaluation did not take place at a qualifying originating site.

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 pay for these items. Our reviewer says that the requested items are not considered medically reasonable and necessary in this case. There is insufficient documentation of an evaluation of the enrollee, and there is insufficient credible objective documentation of joint laxity. The item coded L2397 (sleeve) is not separately payable when the base item is not covered. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria coverage of these items.

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 items have not been met. Therefore, we decided that the Plan does not have to pay for the knee orthosis (L1833) with suspension sleeve (L2397) provided to the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing services provided by an out of network (OON) provider.

You asked the Plan to pay for skilled nursing services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says 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 skilled nursing services provided by an out of network (OON) provider.