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

We decided that the Plan does not have to pre-approve Proton Radiation Therapy Treatment.You asked the Plan to pre-approve Proton Radiation Therapy Treatment. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested services are not medically necessary.The Plan follows Medicare rules. Medicare rules say that Proton Beam Therapy is only covered for certain 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 Proton Radiation Therapy Treatment. Our reviewer says that the documentation does not support that the requested Proton Radiation Therapy Treatment is medically reasonable or necessary. Our physician reviewer found The theoretical advantage of proton beam therapy is in its dose distribution. Proton beam therapy thus permits the delivery of high doses of RT to the target volume while limiting the "scatter" dose received by surrounding tissues. Use of proton beam RT is expanding as more proton beam treatment centers open. However, there are no randomized trials comparing proton beam therapy with photon therapy or brachytherapy in men with clinically localized prostate cancer. A systematic review of the available evidence from ASTRO on efficacy and toxicity concluded that outcomes were similar with proton beam therapy and intensity-modulated radiation therapy (IMRT) using photons but did not demonstrate a benefit for the proton beam approach. Clinical practice guidelines form the American Urological Association (AUA)/American Society for Radiation Oncology (ASTRO)/Society of Urologic Oncology (SUO)/American Society of Clinical Oncology (ASCO) conclude that proton beam therapy offers no clinical advantage over other forms of definitive treatment. Therefore, the enrollee does not meet criteria for the requested services.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Proton Radiation Therapy Treatment have not been met. Therefore, we decided that the Plan does not have to pre-approveProton Radiation Therapy Treatment.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a PET scan.
You asked the Plan to pre-approve a PET scan. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested PET scan is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a PET scan. Our reviewer says that the documentation does not support that the requested PET scan is medically reasonable or necessary. Our physician reviewer found you have an enlarged prostate, negative prostate biopsy despite rising PSAs while on Finasteride for 10 years, and a positive MRI. The documentation shows that your provider did not suspect cancer and did not think ordering a PET/CT is indicated at this time. The documentation does not support that you have an indication for which a PET scan can be covered at this time. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a PET scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a PET scan.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Zoledronic Acid (Zometa) injection
You asked the Plan to pre-approve Zometa. 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 Zometa. 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 prostate cancer met to bones and was found to be worse on recent CT scan. While the documentation does support that the requested use of Zometa is FDA-approved for the enrollee's diagnosis, the plan states that the enrollee must have a dental exam as patients are at risk for osteonecrosis of the jaw. 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 Zometa have not been met. Therefore, we decided that the Plan does not have to pre-approve Zoledronic Acid (Zometa) injection
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services provided on May22, 2019.You asked the Plan to pay forthe laboratory services. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says the services are not covered.The Plan must follow Medicare rules. Medicare rules say that a physician order is not required to be signed, however, the physician must clearly document, in the medical record, his or her intent that the test be performed.We looked at the file and Medicare rules. We find that payment for the lab services is not supported in the medical record. We find that the issue of intent is not clear. There are no medical records in the case file in regards to the physician's intent that the test be performed prior to services taking place.Therefore, we decided that the Plan does not have to pay forthe laboratory services provided on May 22, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and supplies for the enrollee.You asked the Plan to pre-approve a CGM and supplies. You say that this is medically necessary for the enrollee.The Plan denied your request. The Plan says that the enrollee does not meet criteria for coverage.The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered when the above criteria have been met.We looked at the file and Medicare rules. The file indicates the enrollee is not treated by insulin injections three or more times a day. Based on this information, we decided that Medicare rules for coverage of a CGM and supplies have not been met.Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and supplies for the enrollee.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve crown - porcelain/ceramic, tooth #10 and #29 (D2740) and
endodontic therapy, premolar tooth (excluding final restoration), tooth #29 (D3320), for the enrollee.
You asked the Plan to pre-approve the dental services. You say that the services are necessary. The Plan denied
your request. The Plan says that the services are not necessary.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the dental
services when the services are medically necessary and reasonable.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the dental services. Our physician
reviewer found the criteria for a root canal (D3320) and crown restoration (D2740) for tooth #29 have been
met. The bone support appears adequate and there is significant breakdown of the coronal structure.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
the Plan's rules for coverage of the dental services have been met. Therefore, we decided that the Plan has to
pre-approve crown - porcelain/ceramic, tooth #10 and #29 (D2740) and endodontic therapy, premolar tooth
(excluding final restoration), tooth #29 (D3320), 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 to open the case again, we will
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approve IRF care. 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 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 medically necessary. Our physician reviewer found the records show that you were admitted to the hospital for management of an ulcer that developed about a month after surgery for a femur fracture. Your medical issues are stable and you have no complex nursing or rehabilitation needs. There is no documented need for ongoing acute inpatient care. You do not require an intensive therapy program 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveadmission 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 Plansayscare can be received in another setting.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 basedon Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does not require an intensive inpatient rehabilitation therapy program. Based on the medical records provided there is concern that the enrollee will not be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. Care at the skilled nursing facility level or in the home with home health services appears to be more appropriate in this case.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met.Therefore, we decided that the Plandoes not haveto pre-approveadmission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services provided on January 15, 2020.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the claim was submitted after the timely filing limit.The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 must be filed no later than one calendar year after the date of service.The record shows that a claim for the services was not filed until January 31, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed.Therefore, we decided that the Plan does not have to pay forthe services provided onJanuary 15, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genicular nerve ablation.
You asked the Plan to pre-approve genicular nerve ablation. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve genicular nerve ablation. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has chronic Right knee pain due to osteoarthritis. The enrollee's current pain medications are Voltaren gel and Tylenol. The enrollee had a genicular nerve block and achieved 90% pain relief for four weeks. The requested services are considered a experimental/ investigational procedure that is the subject of on-going clinical trials. The enrollee is not enrolled in a clinical trial. Therefore, the request is deemed not medically reasonable or 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 genicular nerve ablation have not been met. Therefore, we decided that the Plan does not have to pre-approve genicular nerve ablation.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from February 13, 2020 through February 19, 2020.You asked the Plan to pay for acute inpatient hospital care. You say that the stay was medically necessary.The Plan denied your request. The Plan says that the stay is not medically necessary.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 pay for acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found given age and presenting signs and symptoms (altered mental status, profound hypoglycemia, hyponatremia, and acute renal failure) it is reasonable that hospitalization is justified. All of these acute problems carry poor outcomes and patient was at very high risk for complication. The admission is justified and was medically reasonable considering the high risks associated with the diagnoses.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met.Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from February 13, 2020 through February 19, 2020.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 power wheelchair.You asked the Plan to pre-approve the requested wheelchair. You say that the enrollee is a high fall risk with chronic respiratory failure.The Plan denied your request. The Plan says no documentation was provided to why the current wheelchair will not meet the enrollee's needs if repaired.The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 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 requested wheelchair. Our physician reviewer found that based on the medical records provided, the documentation does not show that the expense for repairs exceeds the estimated expense of purchasing or renting another item of equipment. The documentation does not show that if repaired, the enrollee's current wheelchair will not meet her needs. Therefore, the requested wheelchair is not medically necessary at this time.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pre-approve a group 2 power wheelchair.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean Axumin PET scan.You asked the Plan to pre-approvean Axumin PET scan. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested services are not medically necessary.The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a PET scan. Our reviewer says that the documentation does not support that the requested PET scan is medically reasonable or necessary. Our physician reviewer found the enrollee has adenoca prostate. The documentation shows that Axumin PET CT is approved PET for men with suspected recurrence based on elevated PSAfollowing prior treatment. The documentation does not support that the enrollee has ever been treated. Therefore, the enrollee does not meet criteria for the requested services.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a PET scan have not been met.Therefore, we decided that the Plan does not have to pre-approvean Axumin PET scan.
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. The Plan denied your request. The Plan says the enrollee has not completed the full course of care in the acute 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 physician reviewer found that the enrollee was admitted to the hospital with MRSA bacteremia and right paraspinal abscess. His course was complicated by infected dialysis access site infections. He required antibiotics, excision of right upper extremity arteriovenous fistula graft, and aspiration of paraspinal abscess. Recent notes show that the enrollee is exhibiting rising white blood cells and new confusion. The enrollee does not require services at the proposed LTACH that are not already available at the current acute care hospital. Based on the recent signs of worsening WBCs, the enrollee does not appear to be stable enough for transfer. Therefore, this request for LTACH services will be considered not medically necessary at this time. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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 pay forprotein; electrophoretic fractionation and quantitation, other fluids with concentration (eg, urine, CSF) (84166), protein; electrophoretic fractionation and quantitation, serum (84165) and immunofixation electrophoresis; other fluids with concentration (eg, urine, CSF) (86335)  on December 9, 2019.You asked the Plan to pay forthe services. You say that the claim should be paid.The Plan denied your request. The Plan says this was not billed as a hospital physician. The Plan states the claim processed to a group with specialty listed as emergencymedicine, and the lab should be billed by the facility.The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. The service was billed with an inpatient hospital (code 21) place of service by a physician group.Therefore, we decided that the Plan doesnot have to pay forprotein; electrophoretic fractionation and quantitation, other fluids with concentration (eg, urine, CSF) (84166), protein; electrophoretic fractionation and quantitation, serum (84165) and immunofixation electrophoresis; other fluids with concentration (eg, urine, CSF) (86335)  on December 9, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laser eye surgery provided on January 30, 2020.

You asked the Plan to waive the copayment for the laser eye surgery. You say that you were never informed that this would be considered an outpatient procedure that would apply a copayment. The Plan denied your request. The Plan says the claim was reprocessed and 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 (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $300 copayment for all other outpatient services not provided in an ambulatory surgical center. 

You have been asked to pay a $300 copayment for the laser eye surgery. The laser eye surgery falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" 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 copayment for the laser eye surgery provided on January 30, 2020.