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

We decided that the Plan does not have to pre-approve admission to a long-term acute care hospital (LTACH) for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says LTACHs do not provide a clinical advantage over a non-LTACH acute care hospital.
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 that in this case, the enrollee was admitted with lower extremity infected ulcers and sepsis. The enrollee required bilateral amputations. The enrollee also required cardiac stent placement. The record indicates that the enrollee has a low hemoglobin and a bowel obstruction at the time of the request. The enrollee is not clinically stable. The enrollee continues to receive acute care services, and these have not been denied. The medical record does not indicate that the enrollee requires services that he is not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules are not
satisfied. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a long-term acute care hospital (LTACH) for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Rituximab Hyaluronidase (J9311).

You asked the Plan to pre-approve Rituximab Hyaluronidase. You say that this drug is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says this requested drug would be a duplicate of the drug regimen.

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 Rituximab Hyaluronidase. Our reviewer says that the requested drug is not medically reasonable and necessary. Our physician reviewer found In this case, the record indicates that the enrollee has mantle cell lymphoma.

The record indicates that the plan has approved coverage for Bendeka, Aloxi, Rituximab and Dexamethasone. The National Comprehensive Cancer Cell Network Drug Compendium, a Medicare approved cancer compendium contains a citation in support of the requested drug for the noted indication. However, the provided records do not indicate that the enrollee has tried and failed Rituximab. The records do not indicate that the enrollee has a contraindication to, or would have an adverse effect from, the plan's preferred agent. In addition, the requested drug would be duplicative of the already approved regimen. The elements of the coverage criteria are not satisfied.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Rituximab Hyaluronidase have not been met. Therefore, we decided that the Plan does not have to pre-approve Rituximab Hyaluronidase (J9311).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for a crown (D2740), and a filling (D2335) provided on March 30, 2021.

You asked the Plan to pay an additional amount for a crown, and a filling. You say that you had to have the filling fixed because you were unsatisfied with the previous provider you saw. The Plan denied your request. The Plan says the services at issue are covered benefits, however the benefit maximum had already been met.

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. 

We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a crown, and a filling have not been met. Specifically, the record shows that you had exhausted your dental benefit maximum. Therefore, we decided that the Plan does not have to pay an additional amount for a crown (D2740), and a filling (D2335) provided on March 30, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 testing provided on February 2, 2021.

You asked the Plan to pay for the services provided. You say that the diagnosis from the testing enabled the physician to determine the optimal treatment for the enrollee. The Plan denied your request. The Plan says the service must be billed as a single procedural service.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

We looked at the file and the rules. We find that the testing was a single procedure. If a single procedure is performed, only one HCPCS/CPT code with one unit of service may be reported for the procedure. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the Guardant360 testing provided on February 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the injection services provided on December 14, 2020.

You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the billed codes and units cannot be verified.

The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the service billed with the modifier indicates a distinct procedural service. 

The file shows that the enrollee received a nutria-pharmaceutical blend. We looked at the file and the rules. The medical records provided do not show that the billed codes were distinct procedural services. The records show that the nutria blend was administered by a pre-filled syringe. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the injection services provided on December 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve clinical crown lengthening (D4249) for tooth # 31.

You asked the Plan to pre-approve the dental service. You say that you have a gap causing discomfort. You say that you have trouble eating. You say that your gum is constantly swelling and bleeding. You also say that you are constantly worrying about infection. The Plan denied your request. The Plan says clinical crown lengthening is not listed as a covered service.

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 pre-approve clinical crown lengthening (D4249) for tooth # 31.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on September 29, 2020.

You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the billed codes cannot be verified.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. 

We looked at the file and the rules. The records do not indicate the enrollee's lab specimen was obtained at an independent laboratory. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on September 29, 2020.
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 records provided support the need for care in an LTACH. The Plan denied your request. The Plan says the enrollee's medical condition is not complex or severe enough to need an LTACH level of care. The Plan says that the enrollee can safely receive the care needed in another setting.

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 was admitted with aspiration pneumonitis. The enrollee requires a jejunostomy tube placement. The enrollee continues to receive acute care services, and these have not been denied. The medical record does not indicate that the enrollee requires services that he is not currently receiving but that would be available at the LTACH facility.

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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve removal of residual tooth roots (cutting procedure) (D7250), consultation - diagnostic service provided by dentist or physician other than requesting dentist or physician (D9310), deep sedation/general anesthesia - first 15 minutes (D9222), and deep sedation/general anesthesia - each subsequent 15 minute increment (D9223).

You asked the Plan to pre-approve the removal of tooth roots, dental consultation and deep sedation/general anesthesia. You say that you would like the services covered. The Plan denied your request. The Plan says these services are not covered under your dental benefits.

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 pre-approve removal of residual tooth roots (cutting procedure) (D7250), consultation - diagnostic service provided by dentist or physician other than requesting dentist or physician (D9310), deep sedation/general anesthesia - first 15 minutes (D9222), and deep sedation/general anesthesia - each subsequent 15 minute increment (D9223).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on October 15, 2020.

You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.

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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the physician services at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay this claim. Therefore, we decided that the Plan does not have to pay for physician services provided to the enrollee on October 15, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis and suspension sleeve provided on March 19, 2021.

You asked the Plan to pay for the provided items. You say that temporary coverage for all telemedicine modalities is allowed. The Plan denied your request. The Plan says there is no established relationship between the enrollee and the ordering physician.

The Plan must follow Medicare rules. The rules state that for any DMEPOS item to be covered by Medicare, the medical record must contain sufficient documentation of the medical condition to substantiate the necessity for the type and quantity of items ordered.

We looked at the file and the rules. The record does not contain valid proof of delivery, or relevant medical records which support medical necessity for the supplies provided in this case. The records do not include previous physical exams, testing, or imaging to confirm a diagnosis or condition. Therefore, we decided that the Plan does not have to pay for the knee orthosis and suspension sleeve provided on March 19, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided from January 30, 2021, to January 31, 2021.

You asked the Plan to pay for the self-administered drugs. You say that you did not have any drugs with you to take. The Plan denied your request. The Plan says the drugs that were provided are considered self-
administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the drugs that were provided are not covered under Medicare 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 pay for the self-administered drugs provided from January 30, 2021, to January 31, 2021.

Benefits for the self-administered drugs 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips.

You asked the Plan to pre-approve routine transportation. You say that you will have follow-up appointments and other transportation needs. The Plan denied your request. The Plan says the denial of authorization for additional routine transportation is correct, because routine transportation beyond 52 one-way trips per calendar year is not covered by the Plan.

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 52 trips per year. 

We looked at your request, the records in the case file, and the rules. Based on this information, we decided that routine transportation beyond 52 trips would not be covered by the Plan's routine transportation benefits. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion of an intrauterine device (IUD).

You asked the Plan to pre-approve IUD. You say that the enrollee has used IUDs in the past with adequate symptom control. The Plan denied your request. The Plan says this service is not covered by Medicare.

The Plan must follow Medicare rules. Medicare rules say that IUDs are not covered by Medicare. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IUD have not been met. Therefore, we decided that the Plan does not have to pre-approve insertion of an intrauterine device (IUD).
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 care is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says rules for LTACH care 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 reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation provided indicating medical necessity for the requested LTACH services. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.

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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient hospital services.

You asked the Plan to pre-approve inpatient hospital services. You say that these services are medically necessary. The Plan denied your request. The Plan says that there is no documentation provided to support the expectation you will require a greater than 2 midnight stay.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.

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 inpatient hospital services. Our reviewer says that inpatient hospital services are not medically reasonable and necessary. You are having an elective non-emergent left knee arthroplasty. You have a medical history of well-controlled diabetes, hypertension, and hypercholesterolemia. Based on the provided documentation, you are a low risk patient and this low risk procedure is not expected to require hospitalization that would likely cross 2 midnights. Our physician reviewer found that your condition does not meet criteria for coverage of inpatient hospital 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 inpatient hospital services have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient hospital services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Orencia (J0129).

You asked the Plan to pre-approve Orencia. The Plan denied your request. The Plan says this request does not meet the Plan's Part B step therapy criteria.

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 Orencia. Our reviewer says that Orencia (J0129) is not medically reasonable and necessary for the enrollee. Our physician reviewer found the Plan requires a trial of the drug Remicade, Inflectra, or Simponi Aria before they will approve the requested drug. Our reviewer found that the enrollee has not tried and failed one of the required drugs. Our physician reviewer also found that there is no documentation indicating that the Plan's required drugs would likely be less effective and/or likely 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 Orencia have not been met. Therefore, we decided that the Plan does not have to pre-approve Orencia (J0129).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the custom fabricated abutment - includes placement (D6057) received December 8, 2020.

You asked the Plan to pay for the custom fabricated abutment. You say that the requested service is necessary. The Plan denied your request. The Plan says the requested service is not covered under your supplemental 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 custom fabricated abutment - includes placement (D6057) received December 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on April 23, 2021.

You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.

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 provider in this case is not a network provider with the Plan. The Plan had network providers available
who could have provided the physician services at issue in this appeal. The Plan did not pre-approve the service
at issue. We found no exception that would require the Plan to pay for this claim, Therefore, we decided that
the Plan does not have to pay for out of network physician services provided to the enrollee on April 23, 2021.