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

We decided that the Plan does not have to pre-approve facet joint injection services.
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the
request is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that facet joint interventions are only covered under
certain medical indications.
We looked at the file and Medicare rules. We find that the services are not indicated. Specifically, the records
show that the enrollee's previous injection yielded zero pain relief. After the first diagnostic facet joint
procedure, there must be a consistent positive response of at least 80% relief of primary pain. 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 facet joint injection services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for Sanexas neoGen-Series therapy (electrical cell stimulation) (97032, 96372, 97112, J3415) subcutaneous Nutri-pharmaceutical blend injections (J3411, J1955, J3420, J3490) and vasopneumatic device therapy (97016) provided on September 4, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for the electrical cell stimulation, injections and vasopneumatic device therapy. You say that the enrollee has tried other modalities and treatments to help relieve the pain that has either failed, had side effects or not alleviate the pain. 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. These procedures are considered investigational and are not eligible for coverage.
The Plan must follow Medicare rules. The rules say that experimental and investigational devices are not covered. 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. These services are considered experimental and investigational. 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 Sanexas neoGen-Series therapy (electrical cell stimulation) (97032, 96372, 97112, J3415) subcutaneous Nutri-pharmaceutical blend injections (J3411, J1955, J3420, J3490) and vasopneumatic device therapy (97016) provided on September 4, 2020 by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound provided on January 20, 2020.
You asked the Plan to waive the copayment for an ultrasound. You say that you disagree with the charges. 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 $0 copayment for allergy testing and a $100 copayment for all other diagnostic tests. You have been asked to pay a $100 copayment for an ultrasound. An ultrasound falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an ultrasound provided on January 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the diagnostic consultation provided by a dentist/physician
other than the requesting dentist/physician (D9310) provided on May 5, 2021.
You asked the Plan to pay for the diagnostic consultation. You say that you did not know these services would
not be covered or that this provider does not participate in Medicare. You feel the Plan should make an
exception as you pay an extra premium for this coverage. The Plan denied your request. The Plan says they
have agreed to cover the surgical tooth extraction and panoramic x-ray, but the diagnostic consultation is not
covered by your dental benefit, regardless of the participation status of the provider.
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 pay for the
diagnostic consultation provided by a dentist/physician other than the requesting dentist/physician (D9310)
provided on May 5, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing (G0480) rendered by the out-of-network (OON) provider on April 22, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without prior authorization.
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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the drug testing (G0480) rendered by the out-of-network (OON) provider on April 22, 2021.
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 you do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. There is a reasonable expectation that this patient will not 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve pain management services to be provided by an out-ofnetwork
(OON) provider.
You asked the Plan to pre-approve OON services. You say that in-network doctors are too far away. 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 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 OON services. Therefore, we decided that the Plan does not have to pre-approve pain
management services to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a seat lift chair.
You asked the Plan to pre-approve the requested chair. You say that you need the chair in order to be functional. The Plan denied your request. The Plan says the chair is not covered by Medicare.
The Plan must follow Medicare rules. The rules say that seat lift chairs are not covered. Coverage is limited to a seat lift mechanism.
The file shows that a seat lift mechanism was approved by the Plan. A seat lift chair was also requested. Although a seat lift chair may be appropriate, Medicare does not cover this item and the Plan must provide coverage only for items that Medicare covers. Therefore, we decided that the Plan does not have to pre-approve a seat lift chair
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the removal of extra skin and tissue of abdomen (15830).
You asked the Plan to pre-approve the removal of extra skin and tissue of abdomen. You say that this request is medically necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met.
The Plan must follow Medicare rules. Medicare rules say that removal of abdominal skin should not be performed until at least 18 months after bariatric surgery. We looked at the file and Medicare rules. In this case, the bariatric surgery you received was performed less than 18 months ago. Based on this information, we decided that Medicare rules for coverage of the removal of extra skin and tissue of abdomen have not been met. Therefore, we decided that the Plan does not have to pre-approve the removal of extra skin and tissue of abdomen (15830).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).

You asked the Plan to pre-approve admission to a SNF. You say that the requested admission to a SNF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF admission.

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 admission to a SNF. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment in a SNF. The documentation does not reveal evidence of complex wound care, new enteral feedings, or other skilled nursing SNF need. The enrollee's functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment in a SNF. The enrollee does not require skilled nursing or skilled therapy services (or a combination of these services) on a daily basis in a SNF. As a practical matter this enrollee does not require the necessary services on an inpatient basis, in a skilled nursing facility setting. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of admission to a SNF have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor.

You asked the Plan to pre-approve the requested device. You say that you have not checked your blood sugars in a long time. The Plan denied your request. The Plan says coverage criteria have not been met.

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 perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of the requested device have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the continuation of inpatient mental health care from October 4, 2021 and forward.

You asked the Plan to pre-approve the continuation of inpatient mental health care from October 4, 2021 and forward. You say that the requested continuation of inpatient mental health care from October 4, 2021 and forward is medically necessary. The Plan denied your request. The Plan says the requested continuation of inpatient mental health care from October 4, 2021 and forward is 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 the continuation of inpatient mental health care from October 4, 2021 and forward. Our reviewer says that the requested continuation of inpatient mental health care from October 4, 2021 and forward is not medically necessary. Our physician reviewer found this enrollee did not appear to require inpatient mental health treatment beyond the date in question as she was not a danger to herself or others, no auditory hallucinations or visual hallucinations while being cooperative with treatment. It did not appear that active treatment was taking place beyond the date in question. It did not appear that the services were reasonably expected to improve the enrollee's condition or for the purpose of diagnosis beyond the date in question. I am unable to find an individualized treatment plan however it is alluded to in the record. It did appear that the records were supervised and evaluated by a physician. Based upon review of the records provided this enrollee does not meet the criteria for continued acute inpatient mental health treatment for the dates in question of October 4, 2021 and forward as this enrollee was not shown to be a danger to herself or others. She was not showing any auditory or visual hallucinations and was cooperative/compliant with treatment. This enrollee was not showing any aggressive behaviors, or any treatment required for acute threats of safety. 

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 continuation of inpatient mental health care from October 4, 2021 and forward have not been met. Therefore, we decided that the Plan does not have to pre-approve the continuation of inpatient mental health care from October 4, 2021 and forward.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care starting October 5, 2021.

You asked the Plan to pay for acute inpatient hospital care. You say that the inpatient admission is medically necessary. The Plan denied your request. The Plan says under Medicare, the request is not medically necessary.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the record sent by the enrollee's provider indicates that she was admitted in order to arrange rehabilitation placement. On evaluation she was not found to have any fractures or active medical problems and she was able to bear some weight and walk without a walker. The review indicates that the record did not show that at the time of inpatient admission the admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier emergency department and/or observation care) would span two midnights. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care starting October 5, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Tecentriq, Paclitaxel, and Carboplatin.

You asked the Plan to pre-approve Tecentriq, Paclitaxel, and Carboplatin. You say that you feel that this plan is the best option for the enrollee. The Plan denied your request. The Plan says these medications in this combination are considered experimental and investigational for the enrollee's diagnosis.

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 Tecentriq, Paclitaxel, and Carboplatin. Our reviewer says that these drugs are not medically reasonable and necessary for the enrollee. Our physician reviewer found the requested use of Tecentriq, Paclitaxel, and Carboplatin is not FDA-approved for the enrollee's diagnosis. Our reviewer found that the use of these drugs is not supported by one of the major drug compendia or by clinical research that appears in a Centers for Medicare & Medicaid Services (CMS) approved medical journal. Our physician reviewer also found that the use of these drugs is not listed as not indicated, not supported or not recommended in any of the compendia. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Tecentriq, Paclitaxel, and Carboplatin have not been met. Therefore, we decided that the Plan does not have to pre-approve Tecentriq, Paclitaxel, and Carboplatin.
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 require treatment by multiple therapies, including either
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. There is a reasonable
expectation that the enrollee will not 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aduhelm.

You asked the Plan to pre-approve Aduhelm. You say that the requested Aduhelm is medically necessary. The
Plan denied your request. The Plan says the requested Aduhelm is not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDAapproved
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 Aduhelm. Our reviewer says that the
requested Aduhelm is not medically necessary. Our physician reviewer found the record indicates that the
enrollee has a seven-year history of progressive cognitive decline and a diagnosis of prodromal Alzheimer's
disease. An MRI result is noted but the primary source document is not submitted. A PET scan is also
referenced but no report provided. The record includes MMSE and SAGE scores that are normal. The
elements of the coverage criteria are not satisfied. The requested service is not 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 Aduhelm have not been met. Therefore, we decided that the Plan does not have
to pre-approve Aduhelm.