Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a right bunionectomy.  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 the 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the submitted records show that you are being treated for a right foot bunion. You have right foot pain from the bunion that has been present for many years. There is no detailed documentation of the noted conservative treatments in the appeal letter. In addition, imaging findings were noted to show no significant hallux valgus deformity. The records do not support that the right bunionectomy is reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a right bunionectomy.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Prednisone for the enrollee.  You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your request. The Plan says that this is not covered under Part B.  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 Prednisone for the enrollee.   Benefits for this drug 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: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a Group 1 standard power operated vehicle (K0800) to be provided by an out-of-network provider.  You asked the Plan to pre-approve a Group 1 standard power operated vehicle. You say that the supplier of the requested item is currently in contract negotiations to become a contracted provider. The Plan denied your request. The Plan says rules for out-of-network care have not been met.  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.  Plan records indicate that 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 Group 1 standard power operated vehicle (K0800) 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 the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF is 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 considered medically reasonable and necessary based on Medicare guidelines.  Our physician reviewer found there is no need for physician supervision 3 times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical conditions. Based upon the current level of function, the enrollee does not require an intensive, complex, multidisciplinary approach to daily therapy. Documentation does not support the need for 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, the rehabilitation needs can be safely met in an alternate and lower intensity 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 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: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a Vertiflex Superion spacer.  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 the 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has chronic back pain with spinal stenosis. The requested Superion spacer is considered experimental/investigational in nature. It is not supported by two learned Orthopedic societies. The procedure 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex Superion spacer.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Keytruda for the enrollee.  You asked the Plan to pre-approve Keytruda. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says that the clinical value and effectiveness of Keytruda in the setting of first line therapy for stage IV hepatocellular has not been demonstrated in the peer-reviewed literature.  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 Keytruda is not medically reasonable and necessary for the enrollee. Keytruda is not FDA-approved for the enrollee's diagnosis. There is no literature or compendia support for Keytruda for the enrollee's diagnosis. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of Keytruda.    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 for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for computed tomography of the head or brain (70450) provided on January 8, 2021.  You asked the Plan to pay for the computed tomography of the head or brain.. You say that you would like reconsideration because the member had multiple exams on the same date of service. The Plan denied your request. The Plan says CPT code 70496 is a more comprehensive procedure which includes imaging procedure 70450 and additional components.  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, we have confirmed that code 70450 is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for computed tomography of the head or brain (70450) provided on January 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a root canal (endodontic therapy) (D3330) for tooth #29.  You asked the Plan to pre-approve a root canal. You say that this service is medically necessary. The Plan denied your request. The Plan says this service is not covered by the enrollee's dental benefit.  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. The Plan does not cover endodontic services.  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a root canal (endodontic therapy) (D3330) for tooth #29.
Appeal type: Step-Therapy
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Synvisc-One.  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 the step therapy requirement is not met.    Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has unilateral primary osteoarthritis of the right knee. He has not tried and failed the Plan's required drugs, Orthovisc and Monovisc. The records do not show that the required drugs would be contraindicated or less effective; therefore, Synvisc-One 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve Synvisc-One.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an inpatient hospital alcohol detoxification stay.  You asked the Plan to pre-approve inpatient alcohol detox stay. You say that you have been experiencing withdrawal when you stop drinking and are at risk of damaging your transplanted liver. The Plan denied your request. The Plan says the denial of authorization for inpatient level of care is correct, because you do not have withdrawal symptoms.  The Plan follows Medicare rules. Medicare rules state that inpatient hospital care may be medically necessary when there is a high probability of complications during detoxification.  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 alcohol detox stay. Our reviewer says that you do not meet the Medicare criteria for the requested inpatient hospital stay. Our physician reviewer found it is not expected that you would improve within a reasonable period of time as you do not have dangerousness to self or others, auditory or visual hallucinations, delusions, or signs of aggressive behavioral issues. It does not appear medically reasonable and necessary to have care provided at the acute inpatient level of care rather than a lower 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 inpatient alcohol detox stay have not been met. Therefore, we decided that the Plan does not have to pre-approve an inpatient hospital alcohol detoxification stay.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and accessory (E0670).  You asked the Plan to pre-approve a pneumatic compression device and accessory. You say that the enrollee experienced pain after two minutes with the basic pump. The Plan denied your request. The Plan says the requirements for coverage have not been met.  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 accessory (E0670).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve wheelchair items and accessories.  You asked the Plan to pre-approve the requested items. The Plan denied your request. The Plan says the enrollee is able to control the power options using their own switches.  The Plan follows Medicare rules. Medicare rules say that wheelchair options and accessories are only covered under certain medical indications.   The file shows that a power seat elevation system was requested. We looked at the file and the rules. A power seat elevation feature (E2300) and power standing feature (E2301) are non-covered because they are not primarily medical in nature. Based on this information, we decided that the Medicare rules for coverage have not been met.   The file shows that an expandable control system was 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 items. Our physician reviewer found that the enrollee has 3-/5 to 3+/5 upper extremity strength. Based on the medical records, there is documentation that the enrollee's upper extremity strength appears to be adequate enough to control the approved power options through their own switches. Therefore, the requested expandable control system does not meet Medicare criteria for medically reasonable and 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 items have not been met. Therefore, we decided that the Plan does not have to pre-approve wheelchair items and accessories.
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 enrollee will benefit from the multi-disciplinary approach that is able to be provided by a long-term team to care and facilitate a smooth transition to a lower level of care. You say that an LTACH admission will help the enrollee regain a maximum/prior level of functioning. The Plan denied your request. The Plan says the records do not support that the enrollee has completed the full course in the hospital. The Plan says that LTACH care is not medically necessary.  The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee was admitted with abdominal pain and peritoneal abscess from perforated colon that required colectomy. The record indicates that the enrollee still requires acute care services as she recovers. The enrollee continues to receive acute care services, and these have not been denied.  The medical record does not indicate that the enrollee requires services that she is not currently receiving but that would be available at the LTACH facility.  The elements of the coverage rules are not satisfied.    The requested service cannot be recommended.  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: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for shoulder surgery you had at an outpatient hospital facility on June 3, 2021.  You asked the Plan to waive the copayment for the shoulder surgery. You say that it would have cost you less to be admitted as an inpatient for this procedure. The Plan denied your request. The Plan says you were kept in observation (which is an outpatient status) for this surgery, so 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 $325 copayment for outpatient surgery.   You have been asked to pay a $325 copayment for the shoulder surgery. The shoulder surgery falls within the outpatient surgery 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 shoulder surgery you had at an outpatient hospital facility on June 3, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for an upcoming ultrasound.  You asked the Plan to waive the coinsurance for the upcoming ultrasound. You say that you feel the copayment for this service is too high. The Plan denied your request. The Plan says the cost sharing will be applied in accordance with your contract.  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 $100 copayment for ultrasounds.   You have been asked to pay a $100 copayment for the upcoming ultrasound. 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 an upcoming ultrasound.
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 enrollee currently meets LTACH admission guidelines. The Plan denied your request. The Plan says the denial of authorization for LTACH service is correct.  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 the enrollee continues to receive acute care services that have not been denied. The record does not show that the enrollee requires services that she is not currently receiving but which would be available at the LTACH.  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 a removable unilateral partial denture (D5282).  You asked the Plan to pre-approve the removable unilateral partial denture. You say that you feel the replacement of the one tooth appliance is necessary for the health of your teeth. The Plan denied your request. The Plan says this service is not covered under your plan.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a removable unilateral partial denture (D5282).