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

We decided that the Plan does not have to pre-approve Fluorouracil and Opdivo 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 the off-label use of this combination for this condition is not medically accepted.
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 the drugs. Our reviewer says that the requested drugs are not medically reasonable or necessary. Our physician reviewer found these drugs are FDA approved for treatment of unresectable advanced, recurrent, or metastatic esophageal squamous cell carcinoma after prior fluoropyrimidine- and platinum-based chemotherapy. This appears to be in combination with fluorouracil/leucovorin. 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 Fluorouracil and Opdivo for the enrollee.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the inpatient services provided May 23, 2020 to May 26, 2020.
You asked the Plan to pay for the inpatient services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says that the services rendered require prior authorization except when an emergency.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 the inpatient services. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee presented to the emergency room with chest pain, arm numbness, abdominal pain and vomiting. The enrollee was admitted to the Intensive Care Unit, evaluated by Neurology and treated with Fentanyl/Versed drip. The documentation shows that the services rendered were an in emergency for admission. Therefore, the services rendered were 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 the inpatient services have been met. Therefore, we decided that the Plan has to pay for the inpatient services provided May 23, 2020 to May 26, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay 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 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 complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for COVID 19 pneumonia and respiratory failure. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that this enrollee will be able 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 IRF admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda.
You asked the Plan to pre-approve Keytruda. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug is not medically 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 documentation does not support that the requested drug is medically reasonable or necessary. Our physician reviewer found the enrollee has already failed programmed cell death protein 1 inhibition. The documentation does not support that the requested drug use is supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journals. 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 Keytruda have not been met. Therefore, we decided that the Plan does not have to pre-approve Keytruda.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex Superion device (CPT code 22869), for the
enrollee.
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your
request. The Plan says the services are considered experimental and investigational.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found the Vertiflex device is experimental. More research is needed to show safety and efficacy of the
device. Open laminectomy is the gold standard procedure.
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 services have not been met. Therefore, we decided that the Plan does not
have to pre-approve the Vertiflex Superion device (CPT code 22869), for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral exam (D0120) and prophylaxis (D1110) provided on February 4, 2020.
You asked the Plan to pay for the dental services. You say that you did not realize that your dentist was not in network with the plan. You say that the services were always covered in the past. You say that you had no way of knowing that your dentist was no longer in network. You say that your dentist, nor the plan told you that he was not in network. The Plan denied your request. The Plan says the provider in this case does not participate with the Plan. The Plan says that dental services that you receive from non-participating dentists are not covered.
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. The Evidence of Coverage clearly states that supplemental dental services must be received from a participating provider in order to be covered by the plan. Therefore, we decided that the Plan does not have to pay for the oral exam (D0120) and prophylaxis (D1110) provided on February 4, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory testing provided on May 23, 2020.
You asked the Plan to pay for the laboratory testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not payable.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The laboratory testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory testing provided on May 23, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve SNF admission. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested 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 in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral medications. The enrollee had stable vital signs. The enrollee was treated for pain with effect. The enrollee required stand-by assistance to supervision for functional mobility including walking to 110 feet with a rolling walker. While the enrollee does require skilled nursing and skilled therapy services, the documentation does not support that the enrollee requires these services on a daily basis. The enrollee's care needs can be met at a lower 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 SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve HPV vaccine (CPT code 90649).
You asked the Plan to pre-approve the HPV vaccine. You say that the HPV vaccine is indicated for the enrollee due to their history of immunodeficiency due to CD4+ lymphopenia. The Plan denied your request. The Plan says the service is not covered by the Plan or Medicare.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the HPV vaccine. The Plan follows the same rules. Preventive immunization (vaccination or inoculation) against such diseases as smallpox, polio, diphtheria, etc., is not covered. The only vaccines that are covered are pneumococcal, hepatitis B, and influenza virus vaccines. Therefore, we decided that the Plan does not have to pre-approve HPV vaccine (CPT code 90649).
Benefits for the HPV vaccine may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is 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 requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation provided necessitating admission to a LTACH. 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 he 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 LTACH services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the skin biopsy procedure you had at an outpatient hospital facility on September 29, 2020.
You asked the Plan to waive the copayment for the skin biopsy. You say that this biopsy procedure was needed to determine if you required further surgery. The biopsy found that you did require further surgery and you underwent a MOHS procedure on December 1, 2020. You stated that because you had to have surgery, you don't think you should have to pay a separate copayment for the biopsy to determine if surgery would be required. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that because the allowed amount for the biopsy ($211.69) is less than your copayment obligation, you are responsible for this full 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 $400 copayment for surgery in an outpatient hospital facility. You have been asked to pay a $400 copayment for the skin biopsy. Biopsies are considered surgical services. This copayment applies regardless of whether or not you require further surgeries. 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 skin biopsy procedure you had at an outpatient hospital facility on September 29, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the urgent care visit and the emergency room (ER) visit.

You asked the Plan to waive the copayments for the urgent care visit and the ER visit. You say that since these visits were on the same dame for the same medical issue, you should only have to pay one copayment. The Plan denied your request. The Plan says you were charged these copayments correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 copayment for each urgent care visit and a $90 copayment for each ER visit.

Records show that you visited an urgent care center and then visited the ER. You have been asked to pay a $50 copayment for the urgent care visit and a $90 copayment for the ER visit. There is no provision in your EOC stating that if you are seen multiple times by different providers on the same day that only one copayment would apply. 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 copayments for the urgent care visit and the emergency room (ER) visit.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on June 21, 2020.
You asked the Plan to pay for the ambulance services. You say that the enrollee was treated in place by the medics. 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 June 21, 2020. 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 provided on June 21, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the combination of Brentuximab and Bleomycin for the enrollee.
You asked the Plan to pre-approve the drug combo. You say that this is medically necessary. The Plan denied your request. The Plan says the use of this drug requires additional information regarding the anaplastic large cell lymphoma, along with the complete chemotherapy regimen.
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 drug combo. Our reviewer says that the requested drugs are not medically reasonable or necessary. Our physician reviewer found the enrollee has already progressed on prior Brentuximab as a single agent. Single agent chemotherapy is recommended for progression as treatment is largely palliative. There is limited data for the combination of bleomycin and brentuximab. 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 the drug combo have not been met. Therefore, we decided that the Plan does not have to pre-approve the combination of Brentuximab and Bleomycin for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the core buildup, including any pins when required, endodontic therapy, and extraction provided on August 19, 2020 by an OON provider.
You asked the Plan to pay for the core buildup, endodontic therapy, and extraction. You say that you believe these services should be covered. The Plan denied your request. The Plan says these services were rendered by an OON provider. The Plan also says that while you are a member of the Plan you must use network providers to receive dental services.
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 core buildup, including any pins when required, endodontic therapy, and extraction provided on August 19, 2020 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on September 4, 2020.
You asked the Plan to pay for the physician's services. 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 did not pre-approve the physician's services. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for physician's services provided on September 4, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide knee brace (L1833) and sleeve (L2397) provided on September 4, 2020.
You asked the Plan to provide knee brace and sleeve. You say that the items are medically necessary. The Plan denied your request. The Plan says insufficient documentation was submitted.
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 provide knee brace and sleeve. Our reviewer says that the requested items are not considered medically reasonable and necessary in this case. Our physician reviewer found there is insufficient documentation of an 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 knee brace and sleeve have not been met. Specifically, there was insufficient documentation to determine the medical necessity of these items. Therefore, we decided that the Plan does not have to provide knee brace (L1833) and sleeve (L2397) provided on September 4, 2020.