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

We decided that the Plan does not have to pre-approve impression and custom preparation, oral prosthesis (21085).
You asked the Plan to pre-approve the dental services. You say that you request the attached supporting medical records be reviewed and the authorization be reconsidered for approval. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. The records do not support that the requested service is medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare covers treatment for TMJ syndrome only when the condition or symptom is medical in nature. The treatment must also be medically reasonable and necessary. 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.. Based on this information, we decided that Medicare rules for coverage of the dental services have not been met. Therefore, we decided that the Plan does not have to pre-approve impression and custom preparation, oral prosthesis (21085).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a stereotactic computer-assisted procedure.
You asked the Plan to pre-approve the requested services. You say that the procedure is to help identify
anatomy and aid with instrument placement. The Plan denied your request. The Plan says medical studies do
not show using this system works better for the spinal surgery.
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 requested services. Our physician
reviewer found that lumbar fusion surgery was approved by the Plan. In this case, there is no medical need for
stereotactic computer assistance for the approved routine lumbar spine surgery fusion. Therefore, the requested
service is not considered medically necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the Plan
does not have to pre-approve a stereotactic computer-assisted procedure
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a cervical laminectomy procedure.
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the code was requested in error.
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 63045 is laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [e.g., spinal or lateral recess stenosis]), single vertebral segment; cervical. We find that CPT code 63045 is not supported in the medical record. Specifically, the file shows that the enrollee is being treated for radiculopathy of the lumbar region. The records do not indicate cervical services are needed at this time. Based on this information, we decided that Medicare rules for coverage of the not been met. Therefore, we decided that the Plan does not have to pre-approve a cervical laminectomy procedure.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF care. You say that the enrollee needs rehabilitation to return home. The Plan denied your request. The Plan says the denial of authorization for SNF care is correct.

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 care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
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 an IRF would be the best fit and allow for you to rebuild your body. You say that IRF care is needed for you to get back to your life. The Plan denied your request. The Plan says the requirements for coverage have not been met.
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 complexity of the member's nursing, medical and rehabilitation needs do not require an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, at an intensive rehabilitation therapy program. There is not a reasonable expectation that this individual will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. The enrollee continues to have a need for skilled therapy with ongoing safety concerns and a potential for functional improvement however, the documentation doesn't support that she would meet criteria for admission to an acute inpatient rehabilitation facility. There is no indication that the enrollee would require skilled rehabilitation in an IRF, participating in rehabilitation services 15 hours a week, under the supervision of a physician with at least 3 visits weekly to regain or maintain her functional status. She can receive services at 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 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 cervical laminectomy, spinal fusion, with inpatient
hospital admission for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your
request. The Plan says the requirements were not met.
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 services. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found there have not been enough conservative measures that have been tried and failed. There are no red flags
for surgery at this time. More physical therapy for neck pain is needed.
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 services have not been met. Therefore, we decided that the Plan does not
have to pre-approve cervical laminectomy, spinal fusion, with inpatient hospital admission for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a battery for a CPAP device.
You asked the Plan to pre-approve a battery for a CPAP device. You say that you need a backup battery in case
of a power outage. The Plan denied your request. The Plan says the requested item is not a covered benefit.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose.
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is a
convenience item. Therefore, we decided that the Plan does not have to pre-approve a battery for a CPAP
device.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Procrit.
You asked the Plan to pre-approve Procrit. You say that you would like reconsideration because the requested
drug is medically necessary. The Plan denied your request. The Plan says the member does not meet step
therapy exception criteria.
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 Procrit. Our reviewer says that the
provided records do not indicate that the enrollee has tried and failed the Plan's preferred step one alternative.
The record does not indicate that the enrollee has a contraindication to, or would have an adverse effect from
the plan's preferred step one alternative. Our physician reviewer found the elements of the coverage criteria are
not satisfied.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Procrit have not been met. Therefore, we decided that the Plan does not have to
pre-approve Procrit
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the continuous glucose monitor (CGM) and insulin pump.
You asked the Plan to pre-approve the CGM and insulin pump. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says no clinical information has been submitted so medical necessity cannot be established.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan. We looked at the file and Medicare rules. The documentation does not indicate that you use insulin with at least three daily injections, require frequent self-adjustment of insulin dosage based on the blood glucose testing results or have had an in-person visit with their treating physician to assesses adherence to your CGM regimen and diabetes treatment plan. Based on this information, we decided that Medicare rules for coverage of the CGM and insulin pump have not been met. Please note, the documentation submitted does not include any clinical records. There is insufficient information to determine if Medicare coverage criteria have been met. Therefore, we decided that the Plan does not have to pre-approve the continuous glucose monitor (CGM) and insulin pump
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.
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 admission is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed 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 these services. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to the hospital
for an elective right knee replacement. She was treated for pain and had stable vital signs. She received
physical therapy in the hospital and needs supervision/stand-by assist for functional mobility, including gait to
100 feet with a rolling walker. She has no skilled nursing needs. She has skilled therapy needs but does not
require skilled therapy on a daily basis. As a practical matter, the enrollee does not require the necessary
services on an inpatient basis at the SNF level of care.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve a skilled nursing facility (SNF) admission
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued care with an out-of-network (OON)
transplant cardiologist located in Spokane, Washington.
You asked the Plan to pre-approve the OON cardiology services. You say that you believe that the enrollee
should be allowed to see the OON cardiologist in Spokane as he can managed her cardiology care since 2014.
The enrollee is to be placed on the transplant list and needs this specialist for these services. The Plan denied
your request. The Plan says the enrollee was under this provider's care but he now practices in Spokane and is
no longer in the Plan's network. There are local cardiac transplant facilities and specialists that can assume the
enrollee's care at this time.
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and
pre-approved care.
We looked at the file and Medicare rules. Although the enrollee has been under this provider's care, the
provider is no longer within the Plan's service area, which is in Oregon. This cannot be considered urgently
needed as the need for these services are not unforeseen as they are being requested prior to leaving the service
area. The Plan has confirmed that there are qualified local cardiac transplant providers able to manage this
enrollee's needs including putting her on the transplant list. Based on this information, we decided that
Medicare rules for coverage of the OON cardiology services have not been met. Therefore, we decided that the
Plan does not have to pre-approve continued care with an out-of-network (OON) transplant cardiologist located
in Spokane, Washington
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a sleep study to be provided by the requested out-of-network provider.

You asked the Plan to pre-approve a sleep study to be provided by the requested out-of-network provider. The Plan denied your request. The Plan says the enrollee must use network providers to get medical care and services when there are network providers available. There is no network gap as there are available in-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 services at issue in this appeal. 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 a sleep study to be provided by the requested out-of-network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an X-ray of the knee (73562) provided by an outpatient hospital on May 28, 2021.
You asked the Plan to waive the copayment for an X-ray. You say that you were under the impression that if an X-ray is performed at a doctor's office, there should be no copayment. You say you thought you would only be charged a copayment if an X-ray is performed at another facility, separate from the doctor's office. The Plan denied your request. The Plan says the claim was processed correctly. The Plan states that the Medicare Allowable rate was determined to be $77.01, which is less than the contractual copayment listed in the EOC for basic radiological services provided in an outpatient hospital setting. The Plan determined you are responsible for this amount in lieu of the full $85 copayment.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay an $85 copayment for Outpatient Diagnostic Tests and Therapeutic Services and Supplies, specifically basic radiological services provided in an outpatient hospital setting. You have been asked to pay a $77.01 copayment for an X-ray. X-rays fall within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. The required copayment for basic radiological services provided by an outpatient hospital is $85, however, since the Medicare Allowed rate of $77.01 is less than the required copayment, you are responsible for the lesser amount. 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 an X-ray of the knee (73562) provided by an outpatient hospital on May 28, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve four (4) additional PT visits.
You asked the Plan to pre-approve four (4) additional PT visits. You say that additional PT is medically necessary. The Plan denied your request. The Plan says additional PT is not medically necessary.
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 four (4) additional PT visits. 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 that based on the available records the enrollee appears to have improved with therapy but still has weakness in the right elbow and wrist. With the now 20 approved physical therapy sessions, further utilization of the home exercise program now appears appropriate. 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. 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 the enrollee's 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 four (4) additional PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve four (4) additional PT visits
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve office visit. You say that you were told this doctor is in-network and you believe this doctor would be the best surgeon to determine the next step of your treatment. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this provider is out-of-network with the Plan and you can be treated by an in-network provider.

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 an office visit to be provided by an out-of-network (OON) provider.
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 you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says there is no support in peer reviewed literature for Keytruda for the enrollee's condition.

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 use of Keytruda is not FDA-approved for the enrollee's diagnosis. Our physician reviewer found the use is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. Of note, the use of Keytruda is supported in Phase I trials, but this case is a Phase III trial.

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.