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

We decided that the Plan does not have to pre-approve a home sleep study with an out of network provider.
You asked the Plan to pre-approve a home sleep study with an out of network provider. You say that you prefer to use the requested provider. The Plan denied your request. The Plan says the requested provider is not in 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 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 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 sleep study with an out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on July 1, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan must pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The 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 out of network physician services provided to the enrollee on July 1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Shock Reducing Pylon (L5988).
You asked the Plan to pre-approve a Shock Reducing Pylon. You say that this is medically necessary. The Plan
denied your request. The Plan says that this exceeds your needs
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 a Shock Reducing Pylon. Our reviewer
says that the requested items/services are not considered medically reasonable and necessary in this case. The
physician documentation does not reveal extenuating factors that would require the shock reducing pylon for
your needs. The request exceeds your medical and functional needs. Our physician reviewer found that your
condition does not meet criteria for coverage of a Shock Reducing Pylon.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of a Shock Reducing Pylon have not been met. Therefore, we decided that the Plan
does not have to pre-approve a Shock Reducing Pylon (L5988).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a sensor for use with an interstitial continuous glucose monitoring system.
You asked the Plan to pre-approve a sensor for use with an interstitial continuous glucose monitoring system. You say that this item will help keep your sugar regulated. The Plan denied your request. The Plan says the requested item is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that CGM devices that do not meet the definition of a therapeutic CGM as defined in CMS Ruling 1682R will be denied as non-covered (no benefit). We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a sensor for use with an interstitial continuous glucose monitoring system have not been met. Specifically, the requested CGM supplies are for a CGM that does not meet the definition of a therapeutic CGM. Non-Therapeutic CGMs are not covered by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve a sensor for use with an interstitial continuous glucose monitoring system.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory services provided on May 11, 2021.
You asked the Plan to waive the copayment for laboratory services. You say that you should not owe a copayment for laboratory services. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $15 copayment for laboratory services provided at an outpatient hospital facility. You have been asked to pay a $15 copayment for laboratory services. Laboratory services fall 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 laboratory services provided on May 11, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda.
You asked the Plan to pre-approve Keytruda. You say that this drug is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage have not been met.
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 requested drug is not medically reasonable and necessary. Our physician reviewer found the enrollee has been diagnosed with stage IV squamous cell carcinoma. The requested use of Keytruda is not approved by the FDA for the enrollee's condition. Furthermore, the use of Keytruda is not supported by one of the major drug compendia or by clinical research that appears in a Centers for Medicare and Medicaid Services (CMS)-approved medical journal. Immunotherapy is not used as a radiosenstitizer. Patient is being treated with radiation for curative intent and pembrolizumab is for locally advanced or metastatic disease not curative with surgery or radiation.
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 Keytruda.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Intracept procedure.
You asked the Plan to pre-approve the Intracept procedure. You say that this procedure is medically reasonable and necessary. The Plan denied your request. The Plan says the requested procedure is considered experimental/investigational.
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 the Intracept procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Intracept procedure is experimental. More research is needed to show safety and efficacy.
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 Intracept procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the Intracept procedure.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive teh copayment for inpatient hospital services you received from June 26, 2021, to July 1, 2021.
You asked the Plan to waive teh copayment for the inpatient hospital services. You say that you were never told that you would be charged and you cannot afford this. The Plan denied your request. The Plan says you were charged this copayment 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 $320 copayment per day for days 1-5 for inpatient hospital services. Records show that you were in the hospital for 5 days. You have been asked to pay a $320 copayment per day for days 1-5 for the inpatient hospital services, for a total of $1600. 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 teh copayment for inpatient hospital services you received from June 26, 2021, to July 1, 2021.
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 LTACH care is medically reasonable and necessary for the enrollee's condition. The Plan denied your request. The Plan says rules for LTACH care have not been met.
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 documentation provided indicating medical necessity for admission to an LTACH. The enrollee is receiving appropriate care at the present acute care hospital. 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.
The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve removal of torus mandibularis (D7473 x 2).
You asked the Plan to pre-approve the dental services. You say that you are aware that this service is not
covered under your dental benefit. You say that this should be covered under your medical benefit because it
has to do with the bone. The Plan denied your request. The Plan says the requested removal of torus
mandibularis are routine dental services. The Plan also says that removal of torus mandibularis is not listed as a
covered dental service.
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 removal of torus
mandibularis are not among those covered under this benefit. Additionally, the services you are asking the Plan
to pre-approve involve the care, treatment, filling, removal or replacement of your teeth or the structures
directly supporting your teeth. These are dental services that are not covered or paid for by Medicare.
Therefore, we decided that the Plan does not have to pre-approve removal of torus mandibularis (D7473 x 2).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.
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. Our physician reviewer found the enrollee does not need a therapy program consisting of at least 3 hours of therapy per day at least 5 days per week with an interdisciplinary approach to rehabilitation care. While the enrollee may benefit from physical therapy and occupational therapy, her rehab needs can be safely met in an alternate and low intensity setting such as a skilled nursing facility or continued therapies at home. 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve aquatic therapy services.
You asked the Plan to pre-approve aquatic therapy services. You say that the requested procedure is medically reasonable and necessary for your condition. The Plan denied your request. The Plan says the provided medical notes do not clearly state the goal of therapy and what improvement is expected.
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 aquatic therapy services. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found you are a 56-year-old female with a past medical history of diabetes, hypertension, dorsalgia, lumbar intervertebral disc disorder and sciatica. Based on the medical records provided there is no documentation that the requested therapy is generally accepted as specific and effective therapy for your condition. Based on the available records, you do not have a diagnosis for which aquatic therapy is covered by the health plan and records do not show the patient has made progress with prior aquatic therapy. Furthermore, 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. Based on the available records, you do not have a diagnosis for which aquatic therapy is covered by the health plan and records do not show the patient has made progress with prior aquatic therapy. Finally, there is no documentation that the specialized skill, knowledge and judgment of a qualified therapist is required to establish, design and/or deliver a program to maintain your current condition or to prevent or slow further deterioration We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of aquatic therapy services have not been met. Therefore, we decided that the Plan does not have to pre-approve aquatic therapy services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the power wheelchair (CPT code K0856).
You asked the Plan to pre-approve the power wheelchair. You say that you are requesting a replacement power wheelchair. The Plan denied your request. The Plan says you have a power wheelchair that is less than five (5) years old.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the power wheelchair have not been met. A power wheelchair from another vendor was approved March 2018. The second power wheelchair is a duplicate service that cannot be covered by Medicare. Medicare criteria are not met for a replacement power wheelchair as you currently have a power wheelchair that is less than five (5) years old.
Therefore, we decided that the Plan does not have to pre-approve the power wheelchair (CPT code K0856).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a wireless capsule endoscopy.
You asked the Plan to pre-approve the wireless capsule endoscopy. You say that the clinical documentation for performing capsule endoscopy is well founded and well documented in this enrollee's case. The Plan denied your request. The Plan says the records show that the enrollee has a pacemaker.
The Plan must follow Medicare rules. Medicare rules say that a colon capsule endoscopy is not medically reasonable and necessary for patients with a cardiac pacemaker or another implanted electro-medical device. We looked at the file and Medicare rules. The record shows that the enrollee had a pacemaker inserted on March 11, 2021. Based on this information, we decided that Medicare rules for coverage of the wireless capsule endoscopy have not been met. Therefore, we decided that the Plan does not have to pre-approve a wireless capsule endoscopy.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve services of a clinical social worker (G0155).
You asked the Plan to pre-approve the services of a clinical social worker. The Plan denied your request. The Plan says Agency Social Work service duplicates service provided by CCA. The Plan also says that services must not be duplicative.
The Plan must follow Medicare rules. Medicare rules say that in order to qualify for coverage under the Medicare home health benefit, a Medicare beneficiary must be confined to the home and be in need of skilled nursing care on an intermittent basis or physical therapy or speech-language pathology or have a continuing need for occupational therapy. We looked at the file and Medicare rules. There is no evidence provided that shows you need intermittent nursing or therapy services, and medical social work cannot be covered under the Medicare home health benefit. Based on this information, we decided that Medicare rules for coverage of the services of a clinical social worker have not been met. Therefore, we decided that the Plan does not have to pre-approve services of a clinical social worker (G0155).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and pneumatic leg appliance (E0667).
You asked the Plan to pre-approve a pneumatic compression device. You say that the items are medically necessary. The Plan denied your request. The Plan says the enrollee does not have lymphedema extending onto the chest, trunk and/or abdomen.
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and pneumatic leg appliance (E0667).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric care from November 4, 2021,
forward.
You asked the Plan to pre-approve inpatient psychiatric care from November 4, 2021, forward. You say that
the services at issue are medically necessary The Plan denied your request. The Plan says the services at issue
are not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the
patient requires active treatment.
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 inpatient psychiatric care from
November 4, 2021, forward. Our reviewer says that you do not meet the criteria for acute inpatient mental
health treatment beyond the date in question of November 4, 2021, forward. Our physician reviewer found you
did not require inpatient mental health treatment beyond November 4, 2021, as you were not a danger to
yourself or others and did not have any delusions, auditory or visual hallucinations. It did not appear that active
treatment was taking place beyond the date in question. It did not appear that the services for the dates in
question were reasonably expected or medically necessary to improve your condition or for the purpose of
diagnosis.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of inpatient psychiatric care from November 4, 2021, forward have not been met.
Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from November 4,
2021, forward.