Persius/hicric huggingface dataset:
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. You say that you want to be treated with Reblozyl. The Plan
denied your request. The Plan says you do not meet the standards for coverage of this drug.
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 Reblozyl. Our reviewer says that the
drug is not medically necessary. Our physician reviewer found Rebloxyl is FDA approved for the treatment of
anemia failing an erythropoiesis-stimulating agent and requiring 2 or more Red Blood Cell units over 8 weeks
in adults with very low- to intermediate-risk myelodysplastic syndromes with ring sideroblasts or with
myelodysplastic/myeloproliferative neoplasm with ring sideroblasts and thrombocytosis. The enrollee has not
been requiring blood transfusions and bone marrow did not indicate ringed sideroblasts. The drug is not
reasonable or medically necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of 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 the enrollee meets the CMS definition for a medically appropriate LTACH admission. The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient acute care and does not require transfer to a LTACH.
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 that although gradual improvement was noted during this acute care stay, acute care appears still required. Vitals, including oxygenation and pulse appear unstable at the time being. The enrollee does not require services at the proposed LTACH that are not already available at the current acute care hospital. There are no services available at the proposed LTACH that the enrollee requires that are not available and covered at the current acute care facility. Therefore, based on the fact that the vitals are still not quite stable enough for transfer and that acute care services are already being appropriately provided, the 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 LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional meals.
You asked the Plan to pre-approve additional meals. You say that you can't cook for yourself. The Plan denied
your request. The Plan says the meal benefit is for up to 7 days.
Medicare generally does not cover meal services. However, the Plan offers a meal benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
We looked at the file and Medicare rules. The documentation shows that you have used 7 days of your meal
benefit. Your plan only covers meals for up to 7 days. Based on this information, we decided that Plan's rules
for coverage of meals have not been met. Therefore, we decided that the Plan does not have to pre-approve
additional meals.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee. You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee is unable to participate in therapy. 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 the admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee 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 skilled nursing facility 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 admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on February 13, 2020.
You asked the Plan to waive the copayment for the ambulance transport. You say that you should not be held liable for these services. The Plan denied your request. The Plan says that this 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 $150 copayment for Medicare-covered one-way ground ambulance transport. You have been asked to pay a $150 copayment for the ambulance transport. The ambulance transport falls within the Medicare-covered one-way ground ambulance transport 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 ambulance transport provided on February 13, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bevacizumab. 
 
You asked the Plan to pre-approve bevacizumab. You say that this is medically necessary. The Plan denied your request. The Plan says that the off label use is not covered. 
 
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 bevacizumab. Our reviewer says that bevacizumab is not medically reasonable and necessary in this case. Bevacizumab is not FDA-approved for your 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. Trials are still phase 1/2 and are only for 1st line treatment. The use is not listed as not indicated, not supported or not recommended in any of the compendia. Our physician reviewer found that your condition does not meet Medicare criteria for bevacizumab. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of bevacizumab have not been met. Therefore, we decided that the Plan does not have to pre-approve bevacizumab.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the enrollee requires intensive therapy to maximize function. The Plan denied your request. The Plan says the enrollee does not have a need for intensive rehab, or a multidisciplinary team for care.
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 is at supervision for eating, moderate assist for sit-to-stand and transfers. She is at total assist for lower body dressing, maximum assist for grooming and upper body dressing, and minimal assist for bed mobility. 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's medical status does not currently require intensive physician and nursing oversight only in an IRF. The enrollee may benefit from multiple therapies, such as physical and occupational therapy, but the documentation does not support that her endurance level can tolerate an intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network tertiary oncologist.You asked the Plan to pre-approve these services. You say that your doctor referred you to this provider.The Plan denied your request. The Plan says the services are available from network providers.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan confirmed that they have a tertiary level provider equipped to provide the same level of care as the requested provider. We found no exception that would require the Plan to pre-approve these items/services.Therefore, we decided that the Plan does not have to pre-approve a referral to an out-of-network tertiary oncologist.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies.
You asked the Plan to pre-approve incontinence supplies. You say that you say the enrollee needs incontinence
supplies. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered
because they are hygienic items that are non-reusable.
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the ultrasound and methylprednisolone
acetate injection provided on April 21, 2020.
You asked the Plan to waive the cost share for the ultrasound and methylprednisolone acetate injection. You
say that you shouldn't be charged a separate copayment for the ultrasound. You say that this is an overcharge.
The Plan denied your request. The Plan says the cost share applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40
copayment for each basic imaging service and 20% coinsurance for Medicare Part B prescription drugs.
You have been asked to pay a total of $42.32 for the ultrasound and methylprednisolone acetate injection. The ultrasound falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit
category. The methylprednisolone acetate injection falls within the "Medicare Part B prescription 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 cost share for the ultrasound and
methylprednisolone acetate injection provided on April 21, 2020.
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. You say that the requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission 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 admission to a LTACH is not medically necessary. Our physician reviewer found the enrollee was admitted to acute care with respiratory distress and left pleurex not working and acute kidney insufficiency. He was treated with BiPAP, bilateral pleurex catheters, vasopressors, thoracentesis, anticoagulation, hemodialysis, and monitoring. He developed new onset atrial fibrillation and treated with amiodarone. He was also treated with IV iron for anemia. Current documentation shows that although he was clinically improving, the enrollee requires regular hemodialysis, speech therapy, physical therapy, and monitoring of his atrial fibrillation and is still having some shortness of breath, warranting additional acute care services for the short-term. Although it appears that the enrollee appears to still require at least short-term use of acute care services, the enrollee does not appear to require services at the LTACH that are not already available at the current acute care facility. There was no indication from the records that the enrollee would require at least an additional 25 days of acute care services to justify transfer to LTACH. There are no services which are available at the proposed LTACH that the enrollee requires that are not already available and covered by the current acute care facility. Therefore, as continued care at the current facility until able to discharge to a lower level of care would be most appropriate according to the notes provided, 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 40mg Uloric Tablets.
You asked the Plan to pre-approve the Uloric Tablets. You say that you would like reconsideration because this is the only option for the member's condition. The Plan denied your request. The Plan says drug coverage for the member is limited to Medicare Part B covered drugs.
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 40mg Uloric Tablets.
Benefits for the Uloric 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance service provided on December 18, 2019.
You asked the Plan to pay for the ambulance service. You say that because of your illness and treatment you
were unable to support yourself and walk. The Plan denied your request. The Plan says you could have been
transported by another means of transportation.
Medicare pays for ambulance services only when an emergency exists or when other means of transport would
endanger the patient's health. The Plan follows the same rules.
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 ambulance service. Our reviewer says
that the service was not an emergent service. Our physician reviewer found the enrollee in this case has a
diagnosis of cancer which was being treated. The enrollee was unable to walk related to weakness as part
following an influenza immunization. Ambulance services were requested. The records provided did not show
this as an emergency. Vitals were stable. The records do not suggest this as an emergency situation. The
enrollee's family could have requested non-emergent transportation such as a stretcher van or wheelchair van
transport company to assist them as no emergency medical care was needed during transportation. There was
no documentation to support any contraindication to using a stretcher van or wheelchair van. The enrollee did
not require medical services during transportation according to the notes. The ambulance transport was not
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 ambulance service have not been met. Therefore, we decided that the Plan
does not have to pay for the ambulance service provided on December 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services (CPT 70450) provided to the enrollee on January 17, 2020.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says another provider billed for the interpretation of the computed tomography.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 70450 is "Computed tomography, head or brain; without contrast material." We asked our coding 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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our coding reviewer found the documentation submitted was reviewed. The documentation of the CT scan is for a different patient. There is no CT noted for a second CT on the same day of service for the same patient. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for radiology services (CPT 70450) provided to the enrollee on January 17, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the rented DME provided to the enrollee on January 22,
2020.
You asked the Plan to pay for the rented DME. You say that the claim should be paid. The Plan denied your
request. The Plan says you did not obtain a prior authorization from the Plan and you did not contact the Plan
to confirm if one is required.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
Review of the file show that the rented DME was provided to the enrollee on January 22, 2020. The enrollee's
EOC states, prior authorization is required for equipment or supplies exceeding $2,500, and for all rental
equipment. There was no prior authorization received from you. The requested provider in this case is not a
network provider with the Plan. The Plan has network providers available who can provide the items/services
at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that
would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay
for the rented DME provided to the enrollee on January 22, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laboratory work provided on January 13, 2020.
You asked the Plan to waive the copayment for the laboratory work. You say that you were not aware that the laboratory work you had done on December 10, 2019 was only good for 30 days prior to your CT scan. You say you should not be responsible for the second laboratory test. The Plan denied your request. The Plan says 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 $20 copayment for all other Medicare-covered lab services. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the $20 copayment for the laboratory work.
You have been asked to pay a $5.55 copayment for the laboratory work. The laboratory work falls within the "Outpatient diagnostic tests and therapeutic services and supplies" 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 laboratory work provided on January 13, 2020.