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

We decided that the Plan does not have to pre-approve Denosumab.
You asked the Plan to pre-approve Denosumab. The Plan denied your request. The Plan says there are no baseline or recent T-scores.
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 Denosumab. Our physician reviewer found that the clinical documentation provided includes the enrollee's Dexa Scan results from 2018, which states her T score is -3.4. The documentation recommends the enrollee to have a follow up exam in 2020. The clinical documentation submitted does not included a recent Dexa Scan. The enrollee was given the medication without any indication if the previous treatments were working, or if she needed to continue the treatment.
The review indicates that the requested use of Denosumab in this case, is not FDA-approved for the enrollee's diagnosis. Its use is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. The documentation does not support that the requested drug is safe and effective and otherwise reasonable and necessary for this enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Denosumab have not been met. Therefore, we decided that the Plan does not have to pre-approve Denosumab.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of SNF care from November 12, 2021,
forward.
You asked the Plan to pre-approve SNF care. You say that the enrollee is a new amputee and needs another
week before they can be discharged safely at home. The Plan denied your request. The Plan says the stay 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 SNF care. Our reviewer says that daily
skilled services are not necessary. Our physician reviewer found the enrollee required skilled rehabilitation
services to improve function due to weakness and deconditioning. There were no skilled nursing needs. As of
November 11, 2021, the enrollee did not require any skilled nursing or rehabilitation services on a daily basis.
The enrollee was not expected to make measurable gains within a reasonable and predictable period of time or
require skilled therapy to prevent deterioration with mobility or activities of daily living (ADLs). The enrollee
did not require skilled therapy to establish a safe and effective maintenance program. As a practical matter, the
enrollee did not require any skilled services on an inpatient basis, at a SNF level of care as of November 11,
2021. The enrollee did not have any parental medications, complex wound care or nutrition given via a feeding
tube. The enrollee received skilled care and improved; however, the enrollee's function had plateaued by
November 11, 2021, and they did not require any further inpatient skilled rehabilitation services. The enrollee's
function was at or near their prior level of function and they could be discharged to a lower level of care for
further services. As of November 11, 2021, the enrollee required custodial services. The denial for further
inpatient skilled care is upheld.
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 continuation of SNF care from November 12, 2021, forward.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from
January 6, 2021, to January 29, 2021.
You asked the Plan to pay for home health services. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the claim is missing required information.
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must
be completed for home health care services to be covered.
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that
Medicare rules for completing the claim for home health services have not been met. Specifically, the claim is
missing the required Federal Information Processing Standard (FIPS) code. Therefore, we decided that the Plan
does not have to pay for the home health services provided to the enrollee from January 6, 2021, to January 29,
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve brachytherapy services.
You asked the Plan to pre-approve brachytherapy services. You say that this procedure is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the requested radiation procedure is not medically reasonable and 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 brachytherapy services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the requested treatment is standard of care for locally recurrent prostate cancer. However, for this patient, there is no pathologic confirmation of recurrent disease and no mention or discussion of this being considered. At this time, it would not be standard of care to consider this treatment without first considering a biopsy, particularly given the risks of this treatment. The consult note mentions that the patient did not want a biopsy, which would perhaps be acceptable if a biopsy were much more invasive and riskier than the procedure.
However, there are biopsy options that are far less invasive and risky than a procedure in which dozens of needs are placed in the prostate. Without biopsy confirmation of recurrent prostate cancer, the treatment would not be in accordance with accepted standards 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 brachytherapy services have not been met. Therefore, we decided that the Plan does not have to pre-approve brachytherapy services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.
You asked the Plan to pre-approve SNF care. You say that you need therapy immediately to assist with recovery. You state you are one-week post operation and have to have therapy to regain mobility. You state you cannot use any of your current durable medical equipment. The Plan denied your request. The Plan says the stay is not medically necessary. The Plan states your needs may be met at a lower level of care, such as, at home with supervision and home health services or at an assisted living facility with home health services.
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 have stabilized medically and are ready for discharge from the hospital. You do not require skilled nursing and/or skilled therapy services on a daily basis. You are medically stable and can receive further rehabilitation services at a lower level of care. Although further rehabilitation services would be appropriate to improve function, as a practical matter, the intermittent skilled services can be provided at a lower level of care than a SNF. You do not have any parental medication; complex wound care or nutrition given via a feeding tube. You are medically stable without any acute exacerbations of chronic medical problems. Your physical function is at or near your baseline and you can receive services at a lower level of care. Admission to a SNF for inpatient skilled rehabilitation services is not 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve three custom fabricated abutments (D6057 x3) and three
abutment supported porcelain/ceramic crowns (D6058 x3).
You asked the Plan to pre-approve the custom fabricated abutments and abutment supported porcelain/ceramic
crowns. You say that your teeth are decayed, and you need them fixed. The Plan denied your request. The Plan
says these services are not covered under your benefit package.
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 three
custom fabricated abutments (D6057 x3) and three abutment supported porcelain/ceramic crowns (D6058 x3).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve eligibility for the Special Supplemental Benefit for the Chronically Ill (SSBCI).
You asked the Plan to pre-approve the SSBCI benefit. You say that you feel that you qualify for this benefit. The Plan denied your request. The Plan says you do not meet the criteria established to receive the Special Supplemental Benefit for the Chronically Ill for 2021.
The Plan must follow Medicare rules. Medicare rules say that there is a special supplemental benefit for enrollees with an eligible chronic condition. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the SSBCI benefit have not been met. Specifically, we have confirmed that you do not have one of the eligible conditions listed in the Evidence of Coverage.
Therefore, we decided that the Plan does not have to pre-approve eligibility for the Special Supplemental Benefit for the Chronically Ill (SSBCI).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the $129.70 applied to the yearly deductible for an office visit provided on June 3, 2021.
You asked the Plan to waive this cost share. You say that you do not believe this cost share is correct. The Plan denied your request. The Plan says this cost share was processed based on the claim submitted by your provided and the Plan contract agreement.
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 $250 deductible for the 2021 Plan year. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan that had not yet been satisfied at the time of service. Therefore, we decided that the Plan does not have to waive the $129.70 applied to the yearly deductible for an office visit provided on June 3, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Human Papillomavirus (HPV) testing provided on
January 11, 2021.
You asked the Plan to pay for the HPV testing. The Plan denied your request. The Plan says this is not a
covered service.
The Plan must follow Medicare rules. Medicare rules say that HPV testing is covered once every five years as
an additional preventive service benefit under the Medicare program for asymptomatic beneficiaries aged 30 to
65 years in conjunction with the Pap smear test.
We looked at the file and Medicare rules. In this case, the enrollee was 74 years old when the HPV testing was
provided. This test is only covered as a preventive service for enrollees aged 30 to 65 years. Based on this
information, we decided that Medicare rules for coverage of the HPV testing have not been met. Therefore, we
decided that the Plan does not have to pay for the Human Papillomavirus (HPV) testing provided on January 11, 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 the enrollee does not require an intensive, complex, multidisciplinary approach to daily therapy. While the enrollee may benefit from physical therapy and occupational therapy, his rehab needs can be safely met in an alternate and low intensity setting such as a skilled nursing facility. 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 radiofrequency ablation services.
You asked the Plan to pre-approve radiofrequency ablation services. You say that the clinical notes provided support the need for the services in dispute. The Plan denied your request. The Plan says the requested injection services are not medically necessary.
The Plan follows Medicare rules. Medicare rules say that facet joint interventions for pain management are covered for certain indications. 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 radiofrequency ablation services. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee has a medical history that includes low back pain. She has failed conservative therapy. She had a series of two diagnostic facet injections performed on July 6 and August 24, 2021, however, the enrollee did not achieve more than 60% improvement with either diagnostic injection. The documented efficacy of the second facet joint block resulted in less than 80% of the initial diagnostic facet joint block which was performed more than two weeks prior to the second diagnostic block, which also provided less than 80% relief. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of radiofrequency ablation services have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation services.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 24 home health physical therapy visits.
You asked the Plan to pre-approve 24 home health physical therapy visits. You say that this requested service is not medically reasonable and necessary. The Plan denied your request. The Plan says the criteria for home health services have not been met.
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 24 home health physical therapy visits. Our reviewer says that the requested home health services are not medically reasonable and necessary. Our physician reviewer found the enrollee does not have documented ongoing home health physical therapy needs. The enrollee is functioning at a level commiserate with a lower level of care. As such, the requested ongoing home health physical therapy services are not medically necessary or reasonable. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 24 home health physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 24 home health physical therapy visits.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda (J9271).
You asked the Plan to pre-approve keytruda. You say that the drug is medically necessary. The Plan denied your request. The Plan says the drug is not medically necessary.
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 service is not medically necessary. Our physician reviewer found the requested used of the drug is not FDA approved or supported by any of the major 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 keytruda have not been met. Therefore, we decided that the Plan does not have to pre-approve Keytruda (J9271).
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the $68.17 copayment charged for emergency room services
provided on June 21, 2021.
You asked the Plan to waive this copayment. You say that you did not see a doctor and they told you at the
emergency department you would not be charged. The Plan denied your request. The Plan says this copayment
was charged based on the claim submitted by the provider. In this case you are being charged less than the
normal contractual copayment of $90.
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 $90
copayment for emergency room services. You have been asked to pay $68.17 for the services received. 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 $68.17 copayment charged for emergency room
services provided on June 21, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a hereditary cardiovascular screening (81407, 81408, 81410,
81411) provided on April 29, 2021.
You asked the Plan to pay for a hereditary cardiovascular screening. You say that this is covered by Medicare.
The Plan denied your request. The Plan says this is not a covered screening service.
The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular
(CV) risk assessment panels, except the basic lipid panel, for symptomatic and asymptomatic patients.
We looked at the file and Medicare rules. The services at issue are a CV risk assessment panel and are not
covered. Based on this information, we decided that Medicare rules for coverage of a hereditary cardiovascular
screening have not been met. Therefore, we decided that the Plan does not have to pay for a hereditary
cardiovascular screening (81407, 81408, 81410, 81411) provided on April 29, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided the Plan does not have to pre-approve out of network physician therapy services for the enrollee.
You asked the Plan to pre-approve these services. You say that this treatment is medically necessary and not available in the network. The Plan denied your request. The Plan says there are providers in network who can treat the enrollee.
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. Your office and staff are not network providers 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 out of network physician therapy services for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the crown for tooth #18.
You asked the Plan to pre-approve the crown. You say that you have an appointment for tooth #12 and want to get both teeth done at the same time. You say that this is a medical necessity and should be approved. The Plan denied your request. The Plan says the provider has not submitted the required documentation to support the need for treatment.
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the crown have not been met. Specifically, medical records were not submitted to determine if the crown is medically necessary and if coverage criteria have been met. Therefore, we decided that the Plan does not have to pre-approve the crown for tooth #18.