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

We decided that the Plan does not have to pre-approve Gilenya.
You asked the Plan to pre-approve Gilenya. You say that the enrollee has done well on this medication. The
Plan denied your request. The Plan says oral medications are not covered.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 Gilenya.
Benefits for Gilenya 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Fentanyl patches.
You asked the Plan to pre-approve Fentanyl. You say that the enrollee has chronic pain and degenerative discs. The Plan denied your request. The Plan says Fentanyl patches to be administered at home is not covered under the Part B 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 Fentanyl patches.
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 the apartment complex where you live called for the ambulance to help you get up and walk back to your apartment. You say that the apartment complex staff are not allowed to touch any residents and therefore called for the service. You stated that the responders escorted you to your apartment and did not transport you. You say you have been told that if you were transported to the hospital the charge would have been less. You stated that this seems wrong. 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 May 28, 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 long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the services are medically necessary. The Plan denied your request. The Plan says the services are not medically necessary.
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 services are not medically necessary. Our physician reviewer found the enrollee was admitted to the hospital on April 3, 2020. He is currently undergoing treatment for VP shunt obstruction for which a shunt replacement was performed. The enrollee has been weaned to tracheotomy collar and is no longer on a ventilator. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Abiraterone for the enrollee.
You asked the Plan to pre-approve Abiraterone. The Plan denied your request. The Plan says that this medication is not covered under Part B.
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 Abiraterone for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nerve conduction studies (95911) and needle electromyography (95886) provided on September 16, 2019.
You asked the Plan to pay for nerve conduction studies and needle electromyography. You say that these services were coded properly. The Plan denied your request. The Plan says the documentation does not support nerve conduction studies were performed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 95911 is nerve conduction studies; 9-10 studies and 95886 is needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; complete, five or more muscles studied, innervated by three or more nerves or four or more spinal levels (List separately in addition to code for primary). 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 nerve conduction studies and needle electromyography. Our reviewer says that these codes are not supported. Our physician reviewer found the documentation supports that needle electromyography, not a nerve conduction test as coded in 95911 was performed. 95886 is an add-on code and therefore not supported. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of nerve conduction studies and needle electromyography have not been met. Therefore, we decided that the Plan does not have to pay for nerve conduction studies (95911) and needle electromyography (95886) provided on September 16, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Metformin HCl ER for the enrollee. You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your request. The Plan says that this is not covered under Part B. 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 Metformin HCl ER for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from August 10, 2019 to September 30, 2019. You asked the Plan to pay for SNF care. You say that this should be covered by Medicare. The Plan denied your request. The Plan says the enrollee no longer needed skilled care for the dates at issue.
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 pay for SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found from a nursing perspective, the beneficiary received oral medications. The beneficiary had stable vital signs. Her lungs were clear. She was treated for a fungal rash under her breasts. Her oral intake was variable. She was treated for a urinary tract infection. She required a mechanical lift for transfers. She had periods of confusion but did not have daily skilled nursing service needs. Regarding rehabilitation services, the beneficiary did not receive nor required any skilled therapy for the dates in question. She did not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 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 care have not been met. Therefore, we decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from August 10, 2019 to September 30, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Tecentriq and Avastin for the enrollee.
You asked the Plan to pre-approve the drugs. You say that this is medically necessary. The Plan denied your request. The Plan says medical studies have not shown that this drug is helpful for treatment of liver cancer, after you have taken other cancer drugs.
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 the drugs. Our reviewer says that the requested drugs are not medically reasonable or necessary. Our physician reviewer found the review relates to a request for Tecentriq (Atezolizumab) and Avastin (Bevacizumab) to treat a 73 year old man with hepatocellular carcinoma (HCC) previously treated with Nexavar and Lenvima. The use of this combination of drugs is not FDA approved nor is it supported in any of the CMS approved compendia. The combination has been reported in patients with no previous systemic treatment (Finn, et al, Atezolizumab plus Bevacizumab in Unresectable Hepatocellular Carcinoma. N Engl J Med. 2020 May 14;382(20):1894-1905.) The enrollee has had previous systemic treatments with Nexavar and Lenvima. Therefore the documentation does not support that the requested combination is medically reasonable and necessary. The documentation does not support that the treatment is safe and effective 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 the drugs have not been met. Therefore, we decided that the Plan does not have to pre-approve Tecentriq and Avastin for the enrollee.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve an epidural injection. You asked the Plan to pre-approve the requested injection. The Plan denied your request. The Plan says that the enrollee has not failed at least 4 weeks of non-invasive treatment. The Plan follows Medicare rules. Medicare rules say that epidural injections are only covered under certain medical indications. 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 injection. Our physician reviewer found that the enrollee has chronic low back pain which radiates to her right buttock. She is taking Hydrocodone with Tylenol, as well as anticonvulsants and Baclofen. She has weakness in muscles on the right innervated by L4, L5 and S1. A positive straight leg raising test is noted on the right. An MRI shows multi-level degenerative disc disease and spinal stenosis at L3-L4 and L4-L5. The progress note states that the enrollee has been doing a home exercise program for 6 weeks, and also notes her chronic kidney disease. The enrollee has failed conservative therapy and has documented indications for an Epidural Steroid trial. Therefore, the request is medically reasonable and necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the requested injection have been met. Therefore, we decided that the Plan has to pre-approve an epidural injection.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 30 additional routine transportation trips.
You asked the Plan to pre-approve the 30 additional routine transportation trips. You say that the enrollee's breast cancer radiation treatments will continue until June 9th. You say that the enrollee needs coverage for the additional routine transportation trips in order to complete radiation treatments and attend follow-up appointments. The Plan denied your request. The Plan says the enrollee has used her benefit allowance for this year.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 24 one-way trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that as of the scheduled trips through May 18, 2020, you will have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve 30 additional routine transportation trips.
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to waive the cost for the laboratory test. We decided that the Plan does not have to waive the cost for the anticoagulant management.
You asked the Plan to waive the copayment for the anticoagulant management and laboratory test. You say that you have never been charged for this test before. You say that you wouldn't have a copayment if you went to a lab. The Plan says that the copayment applied correctly. We decided that the Plan has to waive the cost for the laboratory test.
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 pay a $0 copayment for laboratory tests. The Plan says that you must pay $4.29 for the laboratory test. Based on the Plan contract, however, you cannot be asked to pay more than $0. Therefore, we decided that the Plan has to waive the cost for the laboratory test.
We also decided that the Plan does not have to waive the cost for the anticoagulant management.
You have been asked to pay $11.60, which is less than the standard $20 copayment for the anticoagulant management. Anticoagulant management is considered a physician service. Therefore, we decided that the Plan does not have to waive the cost for the anticoagulant management.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the compression stockings identified with code A6536, A6533 that were issued on March 1, 2019 to March 4, 2019. You asked the Plan to pay for the compression stockings. You say that you did not know the compression stockings would not be covered. The Plan denied your request. The Plan says the stockings are noncovered. The Plan must follow Medicare rules. The rules say that compression stockings described by code A6536, A6533 are noncovered because they are non-reusable supply items. 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 pay for the compression stockings identified with code A6536, A6533 that were issued on March 1, 2019 to March 4, 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. You say that LTACH services are medically necessary. The Plan denied your request. The Plan says LTACHs do not provide clinical advantage over a short term acute care hospitals. Therefore it is not medically necessary for transfer of care to an LTACH.
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 is receiving necessary services and is at an appropriate level of care in the acute care hospital. Continued care at this level is appropriate until the patient is stable to transfer to a lower level of care such as an inpatient rehabilitation facility, a skilled nursing facility, sub-acute rehabilitation facility or home with home health 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 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide twenty additional routine transportation trips for the enrollee.
You asked the Plan to provide additional routine transportation trips. You say that the enrollee needs this to attend medical appointments. The Plan denied your request. The Plan says that the enrollee has exceeded her benefit limit.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of sixty (60) trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Plan does not have to cover routine transportation above benefit maximum of sixty (60) routine transportation. Therefore, we decided that the Plan does not have to provide twenty additional routine transportation trips for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aranesp.
You asked the Plan to pre-approve Aranesp. You say that the requested items/services are considered medically reasonable and necessary in this case. The Plan denied your request. The Plan says the requested items/services are not considered medically reasonable and necessary in this case.
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 Aranesp. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this enrollee does have anemia of chronic kidney disease but may also have some iron deficiency anemia. In order to obtain coverage for Aranesp the ferritin must be 100 (this enrollee's is 33) or an iron saturation greater than or equal to 20% (this enrollee's is 18%). The service is not reasonable or medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Aranesp have not been met. Therefore, we decided that the Plan does not have to pre-approve Aranesp.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.
You asked the Plan to pre-approve these services. You say that the admission is medically necessary. The Plan denied your request. The Plan says the admission is not medically necessary.
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 these services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to the hospital on May 6, 2020 for long-term care after an emergency room visit on April 29, 2020 for a fever. She received oral medications and had stable vital signs. She received physical and occupational therapy in the hospital. She needs maximum assistance with bed mobility and sliding board transfers. She needs varied assistance with activities of daily living. She has no skilled nursing needs. She has skilled therapy needs but does not require skilled therapy on a daily basis. As a practical matter, the enrollee does not require the necessary services on an inpatient basis at the SNF level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete upper denture.
You asked the Plan to pre-approve these services. You say that you need the denture to be able to eat. The Plan denied your request. The Plan says you exhausted the benefit limit.
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 dentures once every five years. The item at issue is a complete upper denture. The file shows that you previously received a denture on October 29, 2019 for which the Plan approved and paid. You are not eligible for new dentures until five years have passed from this date. Therefore, we decided that the Plan does not have to pre-approve a complete upper denture.