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

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the
enrollee.
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary.
The Plan denied your request. The Plan says that the medical necessity for long term acute care admission was
not established by clinical records.
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. The review
has revealed that 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. Our physician reviewer
found that the enrollee's condition does not meet Medicare criteria for LTACH services.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve heart muscle imaging testing.
You asked the Plan to pre-approve the requested testing. You say that the enrollee was referred for an abnormal EKG. The Plan denied your request. The Plan says that screening for coronary artery disease in asymptomatic patients is not medically necessary.
The Plan follows Medicare rules. Medicare rules say that cardiology stress testing in only covered under certain medical indications. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the requested testing. Our physician reviewer found that the enrollee has a history of morbid obesity and hyperlipidemia. A clinic note documents no cardiac symptoms, a normal cardiac physical exam, and an abnormal electrocardiogram. The enrollee has increased coronary risk and evidence of possible old myocardial infarction on electrocardiogram. In this case further evaluation to confirm an old myocardial infarction with imaging, as well as stress testing to assess for any additional silent ischemia is reasonable and appropriate. Current guidelines for nuclear stress testing also consider the test appropriate in this setting. Coverage criteria are met since the test is not a screening procedure, but rather to assess for ischemia with evidence of an old myocardial infarction on electrocardiography. 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 testing have been met. Therefore, we decided that the Plan has to pre-approve heart muscle imaging testing.
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 Heavy-Duty multiple power feature wheelchair and accessories (E2377, E2313, K0843, E2311)
You asked the Plan to pre-approve the Group 2 Heavy-Duty multiple power feature wheelchair and accessories. You say that this type of wheelchair is medically necessary. The Plan denied your request. The Plan says a wheelchair with multiple power options is not necessary. A single power-feature wheelchair would meet the enrollee's needs.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 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 Group 2 Heavy-Duty multiple power feature wheelchair and accessories. Our reviewer says that the requested Heavy-Duty multiple power feature wheelchair is not medically necessary. Our physician reviewer found there is no evidence that the enrollee requires a power tilt or power recline seating system. There is no evidence that the enrollee uses a ventilator, which is mounted to his WC. Therefore, the coverage criteria for K0843 has not been met. 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 Group 2 Heavy-Duty multiple power feature wheelchair and accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 2 Heavy-Duty multiple power feature wheelchair and accessories (E2377, E2313, K0843, E2311)
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for a CT Scan of the head or brain (70450) provided on December 31, 2019.
You asked the Plan to pay for the CT Scan. You say that you would like reconsideration because the member had multiple exams on the same date of service. The Plan denied your request. The Plan says that an appropriate modifier is needed to represent the services are separate and distinct.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The rules also say that MACs subject all line items for the same beneficiary, same NPI, and same date of service to NCCI edits. We find that CPT code 70450 is supported in the record. Specifically, the record indicates that CPT codes 70450 and 70496 were rendered by different providers. NCCI edits do not apply to separate providers with different NPIs. 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 pay for a CT Scan of the head or brain (70450) provided on December 31, 2019.
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on February 17, 2020.
You asked the Plan to pay for the 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 providers must report services correctly. Providers must report services with the appropriate CPT code. We find that the various denied CPT codes are not supported in the medical record. Specifically, the testing at issue in this case should be reported with CPT 81479. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on February 17, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Otezla tablets.
You asked the Plan to pre-approve the Otezla tablets. You say that Otezla is medically necessary for this
enrollee and their treatment of Psoriasis. The Plan denied your request. The Plan says Medicare Part B does not
cover this drug for the enrollee's condition.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Otezla tablets.
Benefits for the Otezla tablets 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: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to make full payment for the office visit. We decided that the Plan does not have
to make full payment for the office visit.
You asked the Plan to make full payment for the office visit. You say that you do not understand why the Plan
did not pay in full for this service. You do not feel that you should have to make payment for this when you
have two insurances. The Plan says that the correct payment of 59 cents was made as the Medicare fee is
$40.59 and there is a $40 copayment.
We decided that the Plan has to make full payment for the office visit.
The Plan follows Medicare rules. Medicare rules say that Plans must protect the enrollee from paying more
than the Plan cost sharing for service even if it is the secondary payer.
In this case, the primary payer applied a $45 copayment for this visit. Since the plan's cost sharing is $40, the
plan must pay $5 to ensure that the enrollee pays no more for the covered service than the plan's contract
allows. Therefore, we decided that the Plan has to make full payment for the office visit.
We also decided that the Plan does not have to make full payment for the office visit.
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 $40
copayment for specialist visits.
With the additional payment described above, you will be asked to pay a $40 copayment for the office visit
with a specialist. 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 make full payment for the office visit.
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pontic (D6245), two retainer crowns (D6740 x2), and a core buildup (D2950).
You asked the Plan to pre-approve the pontic, retainer crowns, and core buildup. You say that these services are medically necessary for your dental health. The Plan denied your request. The Plan says these services 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. Therefore, we decided that the Plan does not have to pre-approve a pontic (D6245), two retainer crowns (D6740 x2), and a core buildup (D2950).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that your do not require daily skilled nursing and/or daily skilled rehabilitation services.
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 reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for continued SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on March 4, 2020.
You asked the Plan to pay for the 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 providers must report services correctly. Providers must report services with the appropriate CPT code. We find that the various denied CPT codes are not supported in the medical record. Specifically, the testing at issue in this case should be reported with CPT 81479. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on March 4, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Durolane.
You asked the Plan to pre-approve Durolane. You say that this is medically necessary. The Plan denied your
request. The Plan says step therapy requirements have not been met.
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 Durolane. Our reviewer says that the
criteria for coverage of Durolane have not been met. Our physician reviewer found the Plan requires a trial of
Orthovisc and Monovisc before they will approve the requested drug. There is no evidence that the enrollee is
allergic to or intolerant of these other forms of hyaluronic acid. There is no evidence that the enrollee has tried
and not responded to these other forms of hyaluronic acid injections. There is no documentation as to why
these other forms of hyaluronic acid would not be expected to be safe and effective for the enrollee.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Durolane have not been met. Therefore, we decided that the Plan does not have
to pre-approve Durolane.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ubrelvy.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied
your request. The Plan says self-administered drugs are not covered.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered
drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Ubrelvy.
Benefits for these services 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the routine eye exam provided on February 27, 2020.
You asked the Plan to pay for the routine eye exam. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says you are limited to one routine eye exam every 12 months. The Plan says that you received a routine eye exam on July 12, 2019, which is less than 12 months ago.
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 once every 12 months. We looked at the file and the Plan's rules. The file shows that you received a routine eye exam on July 12, 2019, which is less than 12 months ago from the February 27, 2020 date of service. Based on this information, we decided that the Plan's rules for coverage of the routine eye exam have not been met. Therefore, we decided that the Plan does not have to pay for the routine eye exam provided on February 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) and a complete mandibular denture (D5120).
You asked the Plan to pre-approve the complete maxillary and mandibular dentures. You say that your gums are in bad shape, and you suffer from a heart condition that would make it worse. You also say that your dentist recommends you have 24 teeth extracted in order to get the dentures. The Plan denied your request. The Plan says these services are not covered 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 a complete maxillary denture (D5110) and a complete mandibular denture (D5120).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Reblozyl.
You asked the Plan to pre-approve Reblozyl. The Plan denied your request. The Plan says coverage of the drug for the enrollee's condition is experimental.
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 Reblozyl. Our physician reviewer found that the requested use of Reblozyl is not FDA-approved for the enrollee's diagnosis. The use is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. There is only phase II data to date in small phase II studies. The use is not listed as not indicated, not supported or not recommended in any of the compendia. The documentation does not support that the requested drug is safe and effective and otherwise reasonable and necessary for this 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 Reblozyl have not been met. Therefore, we decided that the Plan does not have to pre-approve Reblozyl.
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 any further delay in transferring to a 
LTACH will directly jeopardize the enrollee's ability to fully recover and successfully regain maximum 
independence. The Plan denied your request. The Plan says transfer to a LTACH 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 evidence that the enrollee requires services that are not currently available. 
As LTACHs and acute care hospitals are licensed to provide the same level of care, there is no advantage in 
transferring the enrollee to the LTACH. Our reviewer found that the enrollee can remain at the current acute 
care hospital until such time no acute services are required. The enrollee can then be transferred/discharged to a 
lower level of care for any ongoing long term care needs. 
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for 
the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says the care can be safely received in the current hospital 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 based on Medicare guidelines. Our 
physician reviewer found the enrollee was medically stable, with no evidence of need for supervision by PMR 
Physician. There is no need for acute rehab nursing care. Functionally, given her current participation, she does 
not require IRF level of therapies. The enrollee may benefit from further PT and OT but does not require an 
intensive therapy program. IRF admission is not medically necessary based on the enrollee's current 
participation and lack of medical complexity. 
 
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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.