Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says this is not medically 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 enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does not require treatment in an intensive rehabilitation therapy program. Based on the medical records provided there is concern that the enrollee would not be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. Care at the skilled nursing facility level appears to be more appropriate in this case. 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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Durvalumab.
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan denied your request. The Plan says that 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 medically necessary. Our physician reviewer found Durvalumab is FDA-approved for the treatment of unresectable stage III non-small cell lung cancer in adults whose disease has not progressed following concurrent platinum-based chemotherapy and radiation therapy. The enrollee meets this criteria, as his current cancer is eight years after his first lung cancer and is felt to be a second malignancy. He has completed chemotherapy and radiation. The requested drug is reasonable and 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 been met. Therefore, we decided that the Plan has to pre-approve Durvalumab.
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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approveVertiflex interspinous spacer.You asked the Plan to pre-approveVertiflex interspinous spacer. You say that you would like the plan to reconsider their denialThe Plan denied your request. The Plan says the requested services are not medically 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 Vertiflex interspinous spacer. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the requested spacer remains experimental for the use in the spine. More research is needed to support the efficacy of the spacer. Therefore, the enrollee does not meet criteria for the requested 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 Vertiflex interspinous spacer have not been met.Therefore, we decided that the Plan does not have to pre-approveVertiflex interspinous spacer.
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 for the enrollee.
You asked the Plan to pre-approve IRF care. You say that the enrollee will benefit from IRF care. The Plan
denied your request. The Plan says that ongoing skilled services can be provided 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.
Records do not indicate that there are significant, or complex medical/nursing issues that could not be
addressed at a lower level of care. Ongoing pain medication and other medication management, wound care,
and daily therapy can be provided at a lower level of care. The member is mostly MODERATE/MIN assist for
functional transfers and activities of daily living and a less intensive, longer duration of therapy will allow for
measurable gains to be attained within a predicted period. Our physician reviewer found that the enrollee's
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 for the enrollee.
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 you suffer from several medical conditions including a stroke which has limited your mobility and altered your mental status. You say that on the date of service you slipped on water and your life alert was activated. You stated that EMS services were dispatched and upon their arrival you asked for testing. You say you were told that without your own monitor you could not be evaluated. You decided to decline transportation to the emergency room since you had an appointment the next day with your primary care physician. You stated that because of your altered mental status, you refuse to cover the charges which were based on your refusal to be transported. 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 20, 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional inpatient days for a psychiatric admission for the enrollee.
You asked the Plan to pre-approve the additional days. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee is medically stable and tolerating their medicine.
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 the additional days. Our reviewer says that the requested additional days are not medically reasonable or necessary. Our physician reviewer found based upon a review of the records provided, the enrollee does not meet the criteria for continued acute inpatient mental health treatments from June 22, 2020 forward, as the enrolle was not shown to be a danger to herself or others. You were not showing any auditory or visual hallucinations, and were cooperative/compliant with treatment while not showing any threats to safety. 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 additional days have not been met. Therefore, we decided that the Plan does not have to pre-approve additional inpatient days for a psychiatric admission for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveOrthovisc injections.You asked the Plan to pre-approveOrthovisc injections. You say that you would like the plan to reconsider their denialThe Plan denied your request. The Plan says the requested drug is not medically necessary.The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biologicalonly 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 Orthovisc injections. Our reviewer says that the documentation does not support that the requested drug is medically reasonable or necessary. Our physician reviewer found the enrollee has osteoarthritis. Recent literature does not support the use of Orthovisc. It is experimental for knee pain. Therefore, the enrollee does not meet criteria for the requested drug.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Orthovisc injections have not been met.Therefore, we decided that the Plan does not have to pre-approveOrthovisc injections.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for the positron emission tomography (PET) scan rendered on October 7, 2019.You asked the Plan to pay for these services. You say that you disagree with the denial.The Plan denied your request. The Plan says that the diagnosis is not medically necessary.The Plan must follow Medicare rules. Medicare rules say that PET 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 was correct in denying the request to pay for these services. Our reviewer says that the services were medically necessary. Our physician reviewer found the enrollee has hypopharyngeal malignancy. A PET scan for initial staging is covered for this diagnosis. There cords support that the PET scan was reasonable and medically 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 these services have been met.Therefore, we decided that the Plan has to pay for the positron emission tomography (PET) scan rendered on October 7, 2019.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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay fora positron emission tomography (PET) with concurrently acquired computed tomography (CT) coded 78815 provided on December 12, 2019.You asked the Plan to pay fora PET with CT scan. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services were not billed with an acceptable diagnosis code.The Plan follows Medicare rules. Medicare rules say that this code for PET with CT must be billed with a cancer diagnosis code to be 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 a PET with CT scan. Our reviewer says that the documentation does not support that this code was billed with a correct diagnosis code. Our physician reviewer found a positron emission tomography(PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging; skull base to mid-thigh was performed. This code was billed with diagnosis code C16.9 (Malignant neoplasm of stomach). This code was not billed with a diagnosis code that is considered a cancer diagnosis code.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 PET with CT scan have not been met.Therefore, we decided that the Plan does not have to pay fora positron emission tomography (PET) with concurrently acquired computed tomography (CT) coded 78815 provided on December 12, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea portable oxygen concentrator (E1390).You asked the Plan to pre-approvethe portable oxygen concentrator. You say that the oxygen concentrator is medically necessary because it is easier to move around than the oxygen tank you currently use.The Plan denied your request. The Plan says a home oxygen system anda portable oxygen system have already been provided. The enrollee's needs are met by the current equipment provided.The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the samepurpose as equipment already available to an enrollee, it is not considered reasonable and necessary.The file shows that you already have portable oxygen equipment. The portable oxygen equipment serves the same purpose as the portable oxygen concentrator.Therefore, we decided that the Plan does not have to pre-approvea portable oxygen concentrator (E1390).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe chest wall oscillation system (E0483) to be provided by an out of network (OON) provider.You asked the Plan to pre-approvean OON chest wall oscillation system. You say that the OON supplier is medically necessary because they offer the support of a respiratory therapist.The Plan denied your request. The Plan says this item is available 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 provider at issue in this case is not a network provider with the Plan. 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 OON chest wall oscillation system. Our reviewer says that it is not medically necessary to receive this item from an OON provider. Our physician reviewer found it is not considered medically necessary to have a respiratory therapist on call 24/7, or a pulmonologist on staff. The in-network provider is able to provide a functioning device, to instruct and assist the patient in the correct setup and use of the device, and to be reasonably available and accessible as needed during regular business hours.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 OON chest wall oscillation system have not been met. 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 an OON chest wall oscillation system.Therefore, we decided that the Plan does not have to pre-approvethe chest wall oscillation system (E0483) to be provided by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of Keytruda.
You asked the Plan to pre-approve Keytruda. You say that the enrollee needs this medication. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because this drug is not approved for the enrollee's condition.
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 Keytruda. Our reviewer says that the enrollee does not meet the Medicare criteria for use of Keytruda. Our physician reviewer found Keytruda is approved and supported for use in the requested combination for non-small cell lung cancer (NSCLC) when EGFR and ROS mutations are absent. The submitted records do not include information regarding EGFR, ROS, ALK, or other mutation testing. The records say that Caris test results are pending. Therefore, the submitted documents do not support that Keytruda is medically reasonable and necessary, or safe and effective, for 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 Keytruda have not been met. Therefore, we decided that the Plan does not have to pre-approve use of Keytruda.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for filling (D2391) on tooth 28 provided February 5, 2020. 
 
You asked the Plan to pay for the dental services. You say that the filling had chipped and needed to be repaired. The Plan denied your request. The Plan says this service exceeds the benefit frequency limitation. 
 
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. The health plan contract says that the plan will provide coverage for a filling on the same tooth and surface once every 2 years. The records show that a filling was originally provided August 20, 2018.  
 
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 filling (D2391) on tooth 28 provided February 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve periodontal scaling and root planing (D4342) of the lower right quadrant.
You asked the Plan to pre-approve the scaling and planing. The Plan denied your request. The Plan says the criteria states that four teeth in the quadrant must be affected for approval and the enrollee only has one tooth in the quadrant. The Plan also says that it appears this tooth may be extracted.
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. The Plan covers the scaling and planing when the services are medically necessary and reasonable. 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 scaling and planing. Our reviewer says that the service is not medically necessary. Our physician reviewer found the documentation provided does not indicate the presence of 1-3 teeth in the lower right quadrant which would satisfy the criteria for coverage for scaling and root planing (D4342). We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the scaling and planing have not been met. Therefore, we decided that the Plan does not have to pre-approve periodontal scaling and root planing (D4342) of the lower right quadrant.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe custom fabricated abutment and abutment supported porcelain fused to metal crown provided on December 11, 2019.You asked the Plan to pay forthe custom fabricated abutment and abutment supported crown. You say that your provider determined that the best option for you would be an implant. You also say that this was not an elective cosmetic procedure, and should be classified as a crown replacement which is covered by your plan.The Plan denied your request. The Plan says these services are not covered benefits under your dental plan.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 forthe custom fabricated abutment and abutment supported porcelain fused to metal crown provided on December 11, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA).
You asked the Plan to pre-approve the RFA. The Plan denied your request. The Plan says this is not medically necessary.
The Plan follows Medicare rules. Medicare rules say that radiofrequency ablation is covered when the above criteria are met. 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 RFA. Our reviewer says that the requested RFA is not medically reasonable and necessary. Our physician reviewer found that the enrollee is a 74-year-old female with a diagnosis of spondylosis without myelopathy or radiculopathy, lumbar region (M47.816). The records provided document that the enrollee's previous bilateral L2-3, L3-4, and L4-L5 radiofrequency ablation, performed on November 13, 2019, had given her 60% pain relief in the first three weeks. Documentation was not provided that the enrollee has experienced greater than 50% improvement of pain and improvement in patient specific activities of daily living for at least 6 months. 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 RFA have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation (RFA).