Persius/hicric huggingface dataset:
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 the admission. You say that this is medically necessary. The Plan denied your request. The Plan says the medical issues appear to be essentially stabilized.
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 the admission. Our reviewer says that
the requested admission is not medically reasonable or necessary. Our physician reviewer found there are no
identifiable skilled nursing or skilled therapy service needs. You do not require skilled nursing or therapy
services on a daily basis. You do not meet severity of illness or intensity of service criteria for 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 the admission 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Carboplatin, Paclitaxel, and Pembrolizumab for the enrollee.
You asked the Plan to pre-approve the drugs. You say that this is medically necessary. The Plan denied your request. The Plan says this is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the drugs. Our reviewer says that the requested drugs are not medically reasonable or necessary. Our physician reviewer found PD1 inhibition with Opdivo has failed. Thus, treatment with Keytruda would not be reasonable or 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 drugs have not been met. Therefore, we decided that the Plan does not have to pre-approve Carboplatin, Paclitaxel, and Pembrolizumab for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve thoracic spinal fusion with instrumentation.
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 there is no documentation of spinal instability, fracture, or tumor for this enrollee. She has disc degeneration at multiple levels and back pain. The T6 to T10 spinal fusion is not 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 thoracic spinal fusion with instrumentation.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network surgeon at an out-of-network facility.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says the plan covers services from out-of-network providers when the care is urgent, emergent, or not available from network providers.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a referral to an out-of-network surgeon at an out-of-network facility.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for oxygen supplies you received on April 25, 2021.

You asked the Plan to waive the coinsurance for the oxygen supplies. You say that you were told you would have no responsibility for your oxygen equipment for two years The Plan denied your request. The Plan says you were charged this coinsurance 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 20% coinsurance for durable medical equipment and supplies. 

You have been asked to pay 20% coinsurance for the oxygen supplies. There is nothing in your Plan contract that says you will not owe this coinsurance. 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 oxygen supplies you received on April 25, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Brilinta 90mg tablet for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says the requested drug is intended for patient self-administration.
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 Brilinta 90mg tablet for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for Sanexas neoGen-Series therapy (electrical cell stimulation) provided to the enrollee on October 5, 2020.
You asked the Plan to pay for the services. You say that this is medically necessary. The Plan denied your request. The Plan says this is investigational and not covered.
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 pay for the services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our physician reviewer found the clinical value and effectiveness of this request in the setting of chronic pain and paresthesia have not been demonstrated in the peer-reviewed literature. The review has determined that the services at issue in this case are not medically reasonable or 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 services have not been met. Therefore, we decided that the Plan does not have to pay for Sanexas neoGen-Series therapy (electrical cell stimulation) provided to the enrollee on October 5, 2020
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of Opdivo (nivolumab).
You asked the Plan to pre-approve Opdivo. You say that a trial was published with promising results for this
treatment. The Plan denied your request. The Plan says the denial of authorization for this drug is correct,
because Opdivo is not supported for the enrollee's clinical scenario.
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 Opdivo. Our reviewer says that the
enrollee does not meet the Medicare criteria for the requested use of Opdivo. Our physician reviewer found per
National Comprehensive Cancer Network (NCCN) guidelines, for the enrollee's condition the first line is to
treat with platinum-based therapy. Nivolumab is preferred as a second line systemic therapy after platinumbased
therapy. The enrollee has not had platinum-based therapy and no contraindication to such has been
provided, and no PD-L1 test results were included. The requested use of Opdivo is not Food & Drug
Administration approved for the enrollee's diagnosis at this time. Its use is not supported by one of the major
drug compendia or by clinical research appearing in a Medicare-approved medical journal.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Opdivo have not been met. Therefore, we decided that the Plan does not have to
pre-approve use of Opdivo (nivolumab).
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 it is unsafe for you to go to any other level of care.
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 you do not have daily skilled nursing needs
that require the specialized skill, knowledge, and judgment of a skilled professional nurse. You do not have
daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional
therapist. You do 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: SNF
Decision: Favorable

We decided that the Plan has to pay for skilled nursing facility care provided from August 6, 2019, to September 3, 2019.
You asked the Plan to pay for the services. You say that the services were billed correctly. The Plan denied your request. The Plan says that the services at issue should be billed with RVB and AAA instead of RVC10 and RVC20.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We asked our coder 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 the services. Our reviewer says that the services at issue in this case were supported by the medical records. Our reviewer found for the first 14 days of service, the records support that a timely assessment was performed and that the enrollee's ADL score was between 11 and 16 (corresponding to RVC10). On more than three occasions, the enrollee required extensive assistance for toilet use, eating, med mobility and transfer. For the second 14 days of service, the records support a timely assessment was performed, and that the enrollee's ADL score was between 11 and 16 (corresponding to RVC20). On more than three occasions, the enrollee required extensive assistance for toilet use, eating, bed mobility, and transfer. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for skilled nursing facility care provided from August 6, 2019, to September 3, 2019.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for continuation of coverage skilled nursing facility (SNF) services provided to the enrollee from April 19, 2021, to May 18, 2021.
You asked the Plan to pay for the services. You say that this is medically necessary. The Plan denied your request. The Plan says continuation of SNF care 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 pay for the services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing or skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria for 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 the services have not been met. Therefore, we decided that the Plan does not have to pay for continuation of coverage skilled nursing facility (SNF) services provided to the enrollee from April 19, 2021, to May 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a second opinion to be provided by an out-of-network provider.
You asked the Plan to pre-approve a second opinion to be provided by an out-of-network provider. You say that you feel you need the depth of experience that the provider offers. The Plan denied your request. The Plan says the services are available 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 service at issue in this appeal. We found no exception that would require the Plan to pre-approve the service. Therefore, we decided that the Plan does not have to pre-approve a second opinion to be provided by an out-of-network provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for a skilled nursing facility (SNF) admission provided to the enrollee from May 10, 2021, to June 8, 2021.
You asked the Plan to pay for the services. You say that this is medically necessary. The Plan denied your request. The Plan says a SNF 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 pay for the services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing or skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria for 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 the services have not been met. Therefore, we decided that the Plan does not have to pay for a skilled nursing facility (SNF) admission provided to the enrollee from May 10, 2021, to June 8, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health services.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says medical necessity is not established.

The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 

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 medically reasonable and necessary. Our physician reviewer found detailed documentation is not evident showing that you are homebound. Despite the subjective complaints and the noted swelling, the exam does not demonstrate factors that would classify you as homebound. Detailed documentation is not evident regarding why an outpatient therapy program would not be sufficient. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the request for home health physical therapy visits is not medically reasonable or 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve home health services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient behavioral health services.
You asked the Plan to pre-approve inpatient behavioral health services. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
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 behavioral health services. Our reviewer says that the services are not medically necessary. Our physician reviewer found based upon review of the records provided, this patient does not meet the criteria for treatment in an acute inpatient mental
health treatment beyond the date in question of August 25, 2021 forward and could have been treated in a lesser restrictive setting. You were not showing any suicidal or homicidal ideation, auditory or visual hallucinations, or delusions and was not showing any behaviors or aggression. You were being cooperative and compliant while not showing any acute threats to 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 inpatient behavioral health services have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient behavioral health services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on October 12, 2020.

You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says there is no evidence of an established relationship between the member and the ordering physician.

The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a physician who has furnished a consultation or treats an enrollee for a specific medical problem. 

The file does not contain documentation of an established relationship between the enrollee and the ordering provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this testing have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on October 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug/vitamin provided in an injection on March 10, 2021
billed with J7999-KQ-59

You asked the Plan to pay for the drug/vitamin. You say that this is medically necessary and should be covered.
The Plan denied your request. The Plan says this is not covered by Medicare.

The Plan must follow Medicare rules. Medicare rules say that Medicare rules state that in order for physicianprovided
drugs to be covered, the medical records must document the name of the drug administered as well as
the dosage.

Payment for HCPCS/CPT codes J7999 is not supported. Specifically, the record does not contain
documentation of the dosage and type of drug administered in each injection, which is required by Medicare
for these services to be reimbursed. Therefore, we decided that the Plan does not have to pay for the
drug/vitamin provided in an injection on March 10, 2021 billed with J7999-KQ-59