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

We decided that the Plan does not have to pre-approveEstring insertable ring.You asked the Plan to pre-approvethe Estring ring. You say that the enrollee needs this to treat her condition.The Plan denied your request. The Plan says this is a self-administered product which isnot covered by 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 MedicarePart B.Therefore, we decided that the Plan does not have to pre-approveEstring insertable ring.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve computed tomography (CT) services.You asked the Plan to pre-approve the CT scan. You say that the enrollee has a lung nodule and that her sister currently has lung cancer. You say that the enrollee has a smoking history of greater than 40 pack years.The Plan denied your request. The Plan says that the clinical documentation does not show that there are significant signs or symptoms of concern and the pulmonary nodule which was previously identified has decreased in size.The Plan must follow Medicare rules. Medicare rules say that CT 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 pre-approve the CT scan. Our reviewer says that the requested CT scan is medically reasonable and necessary. Our physician reviewer found the enrollee is noted to have a single lung nodule greater than 8mm in size. The nodule was monitored at three months and, per protocol, should be monitored again at 6-12 months. While the nodule did decrease in size between the first and second scan, it is not unreasonable to monitor the nodule one more time to check for resolution or stability. The time period is within the prescribed timeframe.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 CT scan have been met.Therefore, we decided that the Plan has to pre-approve computed tomography (CT) services.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: Surgery
Decision: Favorable

We decided that the Plan has to waive the copayment for the biopsy provided by on March 20, 2019.You asked the Plan to waive the copayment forthe biopsy. You say that the procedure was not necessary and was never performed. You say you should not be responsible for the copayment. The Plan denied your request. The Plan says that you have been charged the correct cost sharing amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that enrollees must pay a $225 per visit, per provider, per day for surgery performed in an outpatient hospital setting. The Plan says you must pay a $225 copayment for the biopsy. Based on the Plan contract, however, you cannot be asked to pay more than a $0 copayment for the biopsy. The medical record clearly shows that the surgery was not performed. Therefore, we decided that the Plan has to waive the copayment forthe biopsy provided on March 20, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF admission and services for enrollee.You asked the Plan to pre-approve SNF services. You say that the enrollee needs to return to a higher level of function.The Plan denied your request. The Plan says the enrollee does not need skilled services on a daily basis in an inpatient facility.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 SNF services. Our physician reviewer found that from a nursing perspective, the enrollee has stable vital signs. There are no identifiable skilled nursing service needs. Regarding rehab services, the enrollee is at a maximal assist to dependent level for bed mobility and transfers. The enrollee requires varying assist with activities of daily living. There are no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission and services for enrollee
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Planhas to pre-approve60 test strips per month for the enrollee. .You asked the Plan to pre-approvethe requested test strips. You say that the enrollee checks blood glucose levels 2 times a day.The Plan denied your request. The Plan says that there is a limit of 50 strips per 30 days for non-insulin users.The Plan follows Medicare rules. Medicare rules say that more than 100 test strips and more than 100 lancets every 3 months are coveredonly 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 test strips. Our physician reviewer found that the enrollee has type 2 diabetes and gastroparesis. The enrollee is on Glipizide and Metformin. Her A1c is 7.7%. The enrollee is at risk for low blood glucose levels given her gastroparesis and glipizide use. Glipizide use can cause low blood sugar, and the delay of gastric emptying can too. Therefore, checking more often 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 test strips have beenmet. Therefore, we decided that the Plan has to pre-approve60 test strips per month for the enrollee.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 toopen the case again, we will send you a letter.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for Thyroprotein Alfa injections (J3240, 96372) provided August 26 to August 27, 2019.
You asked the Plan to waive the coinsurance for the injections. You say that the injections should be included in the procedure. The Plan denied your request. The Plan says the correct coinsurance was applied.
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 20% coinsurance for Part B drugs. You have been asked to pay a 20% coinsurance for the injections. The injections fall within the Part B drugs benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for Thyroprotein Alfa injections (J3240, 96372) provided August 26 to August 27, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.You asked the Planto pre-approveIRF care. You say that this is medically necessary.The Plandenied your request. The Plansaysthe enrollee does not need to be seen by a doctor three times a week.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 is not medically complex enough for this admission. The enrollee was medically stable with no evidence of need for supervision by PMR Physician or needs acute rehab nursing care. She may benefit from further PT and an OT but does not require an intensive therapy program. IRF admission is not medically necessary based on her current functional status and medical stability.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 Plandoes not haveto pre-approveadmission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the vision services provided July 23, 2019 to November 20, 2019.
You asked the Plan to pay for vision services. You say that you were not satisfied with the services you received on July 23, 2019. You knew that your vision was worse and thought it reasonable to get a second opinion. The Plan denied your request. The Plan says vision field test is not a covered benefit. Enrollee's must receive their vision services from an in-network provider.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when rendered by an in-network provider and when indicated as a covered service. We looked at the file and the Plan's rules. vision field test is not a covered service and enrollee's must receive vision services from an in-network provider. Based on this information, we decided that the Plan's rules for coverage of vision services have not been met. Therefore, we decided that the Plan does not have to pay for the vision services provided July 23, 2019 to November 20, 2019.
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-approveIRF care. You say that the enrollee has significant physical and mental health comorbidities which make her recovery more complex.The Plan denied your request. The Plan says the enrollee does not need supervision by an inpatient rehab physician three times a week.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 physician reviewer found that the enrollee has a history of stroke with residual right hemi-body weakness and hyperreflexia, now status post right total hip replacement surgery. The enrollee is now medically stable, but limited. 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 is at moderate to maximum assist for functional transfers and activities of daily living. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program.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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Keytruda (pembrolizumab) immunotherapy treatments.
You asked the Plan to pre-approve the Keytruda treatments. You say that the enrollee would benefit from the
use of this medication. The Plan denied your request. The Plan says that the testing does not clearly indicate
that the mutation markers are negative so this treatment cannot be approved.
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 Keytruda treatments. Our reviewer
says that the requested use of Keytruda is considered medically reasonable and necessary in this case. Our
physician reviewer found the enrollee is a female with metastatic non-small cell lung cancer with PD-L1 of
99% and negative testing for EGFR, ALK, ROS1, and BRAF. The documents submitted include testing by
FoundationOne Liquid reported 2/25/20. The only positive results are MET and TP53 alterations. The findings
listing refers to a complete list of genes assayed in an appendix. The appendix lists ALK, EGFR, ROS1, and
BRAF mutations among others. Since these are not noted to be positive, it is understood that these markers are
negative as positive results were reported explicitly.
The NCCN compendium notes that Keytruda is indicated for treatment for recurrent, advanced or metastatic
disease as first-line therapy for PD-L1 expression-positive (> or =;1%) tumors that are EGFR, ALK, ROS1,
BRAF negative* and no contraindications to PD-1 or PD-L1 inhibitors and performance status 0-2 as a single
agent. The enrollee's tumor has high PD-L1 and is negative for the other mutations. Her performance status is
1. The office notes indicate she has not had prior treatment and the drug will be given as monotherapy. There
are no FDA labeled contraindications of immune related conditions. Therefore, she meets the NCCN
indication. The documentation supports that the Keytruda is medically reasonable and necessary for the patient.
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 Keytruda treatments have not been met. Therefore, we decided that the Plan
has to pre-approve Keytruda (pembrolizumab) immunotherapy treatments.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve a reverse total shoulder replacement procedure.You asked the Plan to pre-approve a reverse total shoulder replacement procedure. You say that the requested reverse total shoulder replacement procedure is medically necessary.The Plan denied your request. The Plan says that the requested reverse total shoulder replacement procedure is not medically necessary.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 pre-approve a reverse total shoulder replacement procedure. Our reviewer says that the requested reverse total shoulder replacement procedure is medically necessary. Our physician reviewer found the enrollee is with a diagnosis of presence of right artificial shoulder joint. The enrollee underwent an open reduction internal fixation (ORIF) in 2016, and a hemi-shoulder arthroplasty in 2018. She haschronic right shoulder pain which is aggravated by range of motion. The enrollee does not have a fever. Range of motion is limited, with pain at the end range. Tenderness is documented distally and laterally. There is extensive scarring. A cortisone injection was beneficial only temporarily. A reverse total shoulder replacement has been requested. The plan denied coverage for the requested procedure, stating that there is no evidence of lab tests to show there is no shoulder infection present.The enrollee has a previous shoulder replacement which has failed, which is an indication for the requested procedure. She has shoulder pain, and decreased function of the shoulder. A cortisone injection has been unsuccessful. The clinical information in the case file supports that the requested reverse shoulder arthroplasty is medically reasonable and necessary for the enrollee in this case. A patient for whom a previous shoulder replacement has been unsuccessful is considered a candidate for reverse total shoulder replacement.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 reverse total shoulder replacement procedure have been met.Therefore, we decided that the Plan has to pre-approve a reverse total shoulder replacement procedure.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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 2 standard power wheelchair and accessories.
You asked the Plan to pre-approve a Group 2 standard power wheelchair and accessories. You say that you need a replacement power wheelchair. The Plan denied your request. The Plan says there is no documentation on your current power mobility device and if it can be repaired.
The Plan follows Medicare rules. Medicare rules say that during reasonable useful lifetime Medicare covers repair for medically necessary equipment. The file does not contain documentation on your current PMD or a repair estimate. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 2 standard power wheelchair and accessories.
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-approvethe LTACH services. You say that LTACH level care is medically necessary.The Plan denied your request. The Plan says coverage criteria has 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 The patient is currently undergoing treatment at an acute care hospital for renal failure. The enrollee is refusing hemodialysis as well as many other interventions. The enrollee is not intubated or ventilated. Admission to a LTACH is not indicated at this time. Therefore, we decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forthe skilled nursing services provided from August 12, 2019 to September 10, 2019.You asked the Plan to pay forthe skilled nursing services. You say that the services that the enrollee required and received are coverable under the Medicare Act.The Plan denied your request. The Plan says the enrollee did not have daily skilled nursing or rehabilitation needs that required an inpatient stay at a SNF.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 the skilled nursing services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNFcare. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 the skilled nursing services have not been met.Therefore, we decided that the Plan does not have to pay forthe skilled nursing services provided from August 12, 2019 to September 10, 2019
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered to the enrollee on April 2, 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 the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered to the enrollee on April 2, 2019.