Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copays for the diagnostic testing services provided on September 30, 2019 and March 23, 2020.
You asked the Plan to waive the copays for the services provided. You say that you should only be paying a $35 copay with a specialist. The Plan denied your request. The Plan says the claims were processed correctly in accordance to your plan benefits.
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 an $85 copay for each covered diagnostic procedure or test at a network doctor's office. You have been asked to pay an $85 copay for each scan of the extremity vein. The services fall within the outpatient diagnostic tests 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 copays for the diagnostic testing services provided on September 30, 2019 and March 23, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a PET/CT scan. 
 
You asked the Plan to pre-approve a PET/CT scan. You say that you would like the Plan to reconsider their 
denial. The Plan denied your request. The Plan says the services are not covered under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of 
qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as 
people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in 
Original Medicare and the plan cost-sharing for the same services. 
 
In this case, you asked the Plan to pre-approve a PET/CT scan as part of a clinical trial. The Plan does not 
cover routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have 
to pre-approve a PET/CT scan.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $25 copayments and 20% coinsurance charged for 
specialist services and Medicare Part B drugs provided from April 10, 2019 to March 20, 2020. 
 
You asked the Plan to waive this cost share. You say that you cannot afford your cost share due to financial 
hardship. The Plan denied your request. The Plan says this cost share is a contractual obligation. 
 
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 $25 
copayment and 20% coinsurance for each specialist service and Medicare Part B Drugs.  
 
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 $25 copayments and 20% coinsurance charged for specialist services and Medicare 
Part B drugs provided from April 10, 2019 to March 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve CardioMEMS. 
 
You asked the Plan to pre-approve CardioMEMS. 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 CardioMEMS. 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 NYSHA Class III congestive heart failure with reduced LV ejection fraction 
(LVEF 20-25%) requiring hospitalization. In this circumstance therapy change based on data obtained from a 
CardioMEMs device has been demonstrated in only one trial to help reduce hospital readmission compared to 
standard medical therapy.  Moreover, concerns have been raised about potential bias in this trial calling into 
question the results. Therefore, the efficacy of the CardioMEMS device is uncertain at this time according to 
leading authorities and not recommended in current guidelines for the treatment of heart failure. 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 CardioMEMS have not been met. Therefore, we decided that the Plan does not 
have to pre-approve CardioMEMS.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission and services. 
 
You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says the enrollee is 
unable to tolerate or significantly benefit from the intensity of inpatient therapies at this time.  
 
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 from a nursing perspective, the 
enrollee had stable vital signs, and received oral and inhaled medications. There are no identifiable skilled 
nursing service needs. Regarding rehab services, the enrollee is at a maximal to dependent assist level with 
functional mobility. The enrollee requires extensive assist with activities of daily living. There are no 
identifiable skilled therapy service needs. She does not require skilled nursing or therapy services on a daily 
basis. The enrollee does not meet severity of illness or intensity of service criteria for 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 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.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of Keytruda.
You asked the Plan to pre-approve Keytruda. You say that you are appealing with records. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because Keytruda is only supported to treat invasive bladder cancer in patients who are ineligible for platinum containing chemotherapy.
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 enrollee does not meet the Medicare criteria for the requested use of Keytruda. Our physician reviewer found the requested use of Keytruda is not approved by the Food & Drug Administration (FDA) for the enrollee's diagnosis. The use of Keytruda is not supported by major drug compendia or by clinical research that appears in a Medicare-approved medical journal. The documentation does not support that the requested drug is safe and effective and otherwise medically reasonable and necessary 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 Keytruda have not been met. Therefore, we decided that the Plan does not have to pre-approve use of Keytruda.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ondansetron tablets.
You asked the Plan to pre-approve Ondansetron tablets. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says Ondansetron tablets are not covered under the enrollee's Medicare Part B benefit.
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 Ondansetron tablets.
Benefits for Ondansetron 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the removal and replacement of fillings (D2391 and
D2393).
You asked the Plan to pre-approve the removal and replacement of fillings. You say that you would like the
Plan to reconsider their denial. The Plan denied your request. The Plan says the 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 the
removal and replacement of fillings (D2391 and D2393).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home ventilator, any type, used with non-invasive 
interface, (e.g., mask, chest shell) (E0466), for the enrollee. 
 
You asked the Plan to pre-approve the home ventilator. You say that the durable medical equipment is 
medically necessary. The Plan denied your request. The Plan says the Medicare rules have not been met. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 home ventilator. Our physician 
reviewer found coverage criteria for a home ventilator are not met. Medicare does not cover a home ventilator 
when used as BiPAP. This patient has been given a diagnosis of chronic obstructive pulmonary disease 
(COPD), but there are no pulmonary function tests to confirm this, and severe COPD would be unusual in a 52-
year-old. The patient has obstructive sleep apnea (OSA) and morbid obesity, and obesity-hypoventilation 
syndrome is a more likely diagnosis. However, there are no arterial blood gas data to confirm elevated pCO2.  
Medicare does not cover a home ventilator for the treatment of obesity-hypoventilation.  Certain BiPAP 
devices are capable of providing the AVAPS-AE mode of support that is ordered.  A home ventilator is not 
medically necessary, and the denial is upheld. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve home ventilator, any type, used with non-invasive interface, (e.g., mask, chest shell) 
(E0466), for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint blocks. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
enrollee has had prior injections that have provided little to no relief. 
 
The Plan follows Medicare rules. Medicare rules say that facet joint interventions are only covered under 
certain medical interventions. 
 
The documentation shows that facet joint injections at L3-S1 were requested. 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 services. Our physician reviewer found that the office notes 
document that the enrollee has had prior transforaminal injections at L5-S1 bilaterally with short lasting, 20% 
relief. The office note dated documents L3-4 facet nerve block on June 25, 2020, with 30-40% relief which 
lasted 5-6 hours. The provided medical records do not document that the enrollee has satisfied the coverage 
criteria. Therefore, the requested services are 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet joint blocks.
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 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 admission. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found you received oral medications and 
insulin. You had stable vital signs. You required stand-by assistance with transfers. The documentation does 
not support that you require the specialized skills, knowledge, or judgment of a skilled professional nurse or 
qualified therapist to safely and effectively provide medically necessary and reasonable treatment. The 
documentation does not support that skilled nursing or skilled therapy services are required on a daily basis. As 
a practical matter, you do not require the necessary services on an inpatient basis, at a SNF 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a heavy duty hospital bed. 
 
You asked the Plan to pre-approve the requested bed. You say that your current hospital bed is too short and 
narrow. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that heavy duty hospital beds are only covered under 
certain medical indications.  
 
We looked at the file and Medicare rules. The records provided do not indicate that you meet the weight 
criteria for the requested hospital bed. 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 heavy duty hospital bed.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve continued inpatient psychiatric services. 
 
You asked the Plan to pre-approve continued inpatient services. You say that the enrollee will have a stronger 
recidivism if the requested services are not approved. The Plan denied your request. The Plan says that the 
enrollee does not have acute symptoms that require 24-hour care. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
The file shows that continued inpatient services were requested beyond August 19, 2020. 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 continued inpatient services. Our physician reviewer 
found that the enrollee is a danger to himself but not others. It did appear that active treatment was taking 
place. The services for the dates in question are reasonably expected or medically necessary to improve the 
enrollee's condition. The services were supervised and evaluated by a physician. Based upon review the 
records provided, this patient does meet the criteria for treatment in an acute inpatient mental health treatment 
beyond the date in question of August 19, 2020 forward. He was showing suicidal, but no homicidal ideation, 
auditory or visual hallucinations. He was not showing any behaviors of being cooperative and compliant. 
Therefore, the requested services are 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 continued inpatient services have been met. Therefore, we decided that the Plan 
has to pre-approve continued inpatient psychiatric 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued physical therapy services. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says you 
have been given sufficient visits to finalize a home exercise program. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 services. Our physician 
reviewer found that you have received outpatient physical therapy for knee, ankle, and low back pain. There is 
no documentation that the unique skills of a professional therapist are required to safely and effectively provide 
treatment, that the services can be safely and effectively performed only by a therapist, or under the supervision 
of a therapist.  You have received 26 treatments for your conditions, and are showing no further progress in 
recovery. Therefore, further treatments do not appear to be 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued physical therapy services.
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 continued services. You say that you need more rehab. The Plan denied 
your request. The Plan says you do not require care by a nurse or therapist on an inpatient basis. 
 
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 continued services. Our physician 
reviewer found that from a nursing perspective, you had stable vital signs, your lungs were clear, and you were 
treated for pain with effect. There are no identifiable skilled nursing service needs. Regarding rehab services, 
you are at a contact guard to minimal assist level with functional mobility. You require varying assist with 
activities of daily living. There are no identifiable skilled therapy service needs. You do not require skilled 
nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria 
for 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 continued 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the manual wheelchair provided on January 28, 2020. 
 
You asked the Plan to pay for the manual wheelchair. You say that the enrollee needs a manual wheelchair. 
The Plan denied your request. The Plan says information supporting the criteria was not provided. 
 
The Plan follows Medicare rules. Medicare rules say that a manual wheelchair 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 or cane, or the patient is not capable of self-propelling the manual wheelchair. 
 
The file does not support the criteria and there was no prior authorization. This means that Medicare rules for 
coverage of a manual wheelchair have not been met.  
 
 
 
Therefore, we decided that the Plan does not have to pay for the manual wheelchair provided on January 28, 
2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the health club membership fee towards the 2019 Wellness 
benefit. 
 
You asked the Plan to pay for the health club membership fee. You say that your submission was rejected 
because you mistakenly put 2019 on the claim form and it should have been 2018 and you feel that this should 
be paid. The Plan denied your request. The Plan says based on the review of the submitted proof of payment, 
the $250 wellness benefit was already reimbursed. Duplicate payment would result in overpayment. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. The Plan will reimburse up to 
$250 each calendar year towards your cost for membership in a qualified health club or fitness facility. 
 
The Plan's rules for coverage of gym benefits have not been met because based on the review of the submitted 
proof of payment, the $250 Wellness benefit was already reimbursed. Duplicate payment would result in 
overpayment.. Therefore, we decided that the Plan does not have to pay for the health club membership fee 
towards the 2019 Wellness benefit.