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

We decided that the Plan has to pre-approve fosaprepitant and palonosetron HCl.
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 that the services are not medically necessary.
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 these services. Our reviewer says that
the services are medically necessary. Our physician reviewer found the enrollee has malignant neoplasm of
overlapping sites of bladder. Carboplatin with an AUC of 4 is planned as combination therapy with
gemcitabine. Carboplatin at this dose is considered highly emetogenic and the use of palonosetron and
fosaprepitant would be considered a standard of care. The service is reasonable and 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 these services have been met. Therefore, we decided that the Plan has to preapprove
fosaprepitant and palonosetron HCl.
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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Zarxio.
You asked the Plan to pre-approve Zarxio. You say that the requested Zarxio is medically necessary. The Plan denied your request. The Plan says the requested Zarxio is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved 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 Zarxio. Our reviewer says that the requested Zarxio is not medically necessary. Our physician reviewer found the enrollee is diagnosed with recurrent ovarian cancer. The requested use of Zarxio is not FDA-approved for the enrollee's diagnosis. Guidelines for gemcitabine recommend dose reduction for neutropenia. The use of Zarxio for the enrollee's condition is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Zarxio have not been met. Therefore, we decided that the Plan does not have to pre-approve Zarxio.
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 your life and health is in danger without the requested medical services. The Plan denied your request. The Plan says that you can safely receive the services you need in other settings.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for surgical repair of a hip fracture after a fall. Your medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your condition does not meet Medicare criteria for IRF 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 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation.
You asked the Plan to pre-approve additional trips. You say that the enrollee relies on transportation to attend his appointments. The Plan denied your request. The Plan says the enrollee has used 12 one-way trips for this service.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 12 one-way trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the enrollee has exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral exam (D0120).

You asked the Plan to pay for the dental service. You say that you did not have a full exam. You say that you were advised that you needed to return for a full exam. You say that you followed the dentists advise. You say that the exam denied for frequency limitation. You also say that this service should be covered as you get 2 routine exams per year. The Plan denied your request. The Plan says 2 oral exams are covered per calendar year. The Plan also says that the frequency limit has been exceeded.

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 and oral exams are a covered service, the frequency limit has been exceeded. The record shows that the Plan paid for oral exams. Therefore, we decided that the Plan does not have to pay for the oral exam (D0120).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nursing facility care provided by an out-of-network provider.

You asked the Plan to pay for the nursing facility care. You say that the enrollee was unable to obtain a referral for himself. The Plan denied your request. The Plan says prior authorization was required but not obtained.

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.

The requested provider in this case is not a network provider with the Plan. 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 nursing facility care provided by an out-of-network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for an outpatient surgery provided by an out-of-network.

You asked the Plan to waive the deductible for an outpatient surgery. You say that you do not agree with this
deductible. The Plan denied your request. The Plan says the correct deductible has been applied.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your
contract with the Plan says that there is a $1,408 deductible for outpatient surgery/out-of-network.

The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient
surgery/out-of-network. The Plan has followed Medicare rules by clearly disclosing in the contract that there is
a $1,408 deductible for outpatient surgery/out-of-network. This cost sharing is a contractual obligation that had
not been met at the time an outpatient surgery. The total amount you are being asked to pay is $670.05. 
Therefore, we decided that the Plan does not have to waive the deductible for an outpatient surgery 
provided by an out-of-network.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing services provided by an out of network (OON) provider.

You asked the Plan to pay for skilled nursing services. You say that these services were provided at a skilled nursing facility. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that the rendering skilled nursing facility is also out-of-network.

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.

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided 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 skilled nursing services provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Synvisc injection.

You asked the Plan to waive the coinsurance for the Synvisc injection. You say that you were advised the injection was covered without a deductible or copayment. You say that you would have canceled the injection if you were advised differently. The Plan denied your request. The Plan says the claim reprocessed to only apply coinsurance for the injection.

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 20% coinsurance for chemotherapy drugs and 20% coinsurance for all other drugs covered under Medicare Part B.

You have been asked to pay $103.02, which is 20% of the allowed amount for the Synvisc injection. The allowed amount is $515.09 (20% x $515.09 = $103.02). The Synvisc 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 coinsurance for the Synvisc injection.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 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 records show that it is not likely that the enrollee will require
hospital-level care for 25 days or more.

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 patient
appears to be improving; however, they need additional short-term acute care services that can safely be
completed at the current facility. The patient does not require services at the LTACH that are not already
available at the current facility. 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 LTACH services for the enrollee.
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 necessary to properly get better. The Plan denied your request. The Plan says that progression of dementia is limiting your ability to participate in physical and occupational therapy.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network facility.

You asked the Plan to pre-approve these services. You say that the enrollee is unable to meet his nutritional needs. 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. 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 facility.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that an IRF admission is medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of an IRF admission.
The Plan must follow Medicare rules. The rules say that an IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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 that the complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for COVID 19 pneumonia. Her medical problems are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care.
Additionally, there is not a reasonable expectation that this patient will be able to fully participate in and benefit from the 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 an acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the Hizentra intravenous immune globulin (IVIG) and related supplies provided on June 9, 2020.
You asked the Plan to pay for the Hizentra IVIG and supplies. You say that these items were medically necessary and should be paid. The Plan denied your request. The Plan says there is no documentation of POD in the case file, despite requests.
The Plan must follow Medicare rules. Medicare rules say that POD must be available on request. For items delivered directly, there must be a signature and date which is used as the DOS. In this case, it appears that the items were delivered directly by the supplier. The file includes a delivery ticket which appears to correspond to the items billed. However, this appears to have been initialed and dated by the supplier for May 27, 2020. There is nothing which corresponds to the reported date of service, June 9, 2020. Without documentation of items delivered on this date, we find that the claim is not supported as billed. Therefore, we decided that the Plan does not have to pay for the Hizentra intravenous immune globulin (IVIG) and related supplies provided on June 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cataract surgery to be provided by an out-of-network
provider.
You asked the Plan to pre-approve ophthalmological procedure (92499) and Astigmatism correcting function
of intraocular lens (V2787). You say that the requested procedure is necessary because the enrollee's cataract is
extremely dense. The Plan denied your request. The Plan says astigmatism correcting intraocular lenses are not
covered by Medicare and they have in network providers that can provide approved extracapsular cataract
removal with insertion of intraocular lens prosthesis (66984)
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 service at issue in this appeal. Astigmatism correcting function of intraocular
lens (V2787) is not covered by Medicare or the Plan. We found no exception that would require the Plan to
pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve cataract surgery
to be provided by an out-of-network provider.
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 you disagree with the denial. 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 in the Medicare rules section. 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 you were admitted to the hospital on April 7, 2021 for knee replacement surgeries. Your medical problems are stable and you have no complex medical or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. There is not a reasonable expectation that you will be able to fully participate in and benefit from the 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the panoramic x-ray (D0330).

You asked the Plan to pay for the dental service. You say that you are being charged for a service that you did
not request. You say that you are covered for a full mouth x-ray, D0210. You also say that you are being
charged for a panoramic x-ray. The Plan denied your request. The Plan says panoramic x-ray is not listed as a
covered service. The Plan says that the billed charge is $137. The Plan says that the allowed amount for this
service is $70.04. The Plan also says that you are responsible for the allowed amount of $70.04 for the
panoramic x-ray.

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, panoramic x-ray is not among those
covered under this benefit. Therefore, we decided that the Plan does not have to pay for the panoramic x-ray
(D0330).