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

 We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care after November 6, 2021.  You asked the Plan to pre-approve SNF care. You say that you are not getting service at the facility but need therapy. The Plan denied your request. The Plan says the denial of authorization for continued SNF care after November 6, 2021 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 continued skilled nursing facility (SNF) care after November 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve proton beam radiation therapy.  You asked the Plan to pre-approve proton beam radiation therapy. You say that proton beam therapy is a proven treatment option and should be covered because it is the standard of care to treat the enrollee's breast cancer. You say that proton beam therapy is the only modality that can prevent overlapping fields and additional dose to the lung and surrounding normal tissue. The Plan denied your request. The Plan says the requested type of treatment is not medically necessary. The Plan says that no definitive data exists to suggest that protons are superior to photon intensity-modulated radiation therapy (IMRT) for breast cancer.  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 proton beam radiation therapy. Our reviewer says that proton beam radiation therapy is not considered medically reasonable and necessary in this case. Our physician reviewer found routine use of proton therapy for breast cancer is not an accepted standard of care. While proton therapy can be used (and is often used for select patients with unique anatomic considerations) the case file does not provide a plausible rationale for the need of proton therapy over conventional radiation and/or IMRT in this patient.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of proton beam radiation therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve proton beam radiation therapy.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.  You asked the Plan to pre-approve the SNF services. You say that it isn't safe for the enrollee to go home, as she cannot do anything for herself and doesn't have anyone at home to help take care of her. You say that you are afraid the enrollee will die if she doesn't receive SNF care before going home, because she is very weak and helpless. The Plan denied your request. The Plan says the guidelines for coverage of SNF care have not been met. The Plan says that the services required can safely be received at a different setting.  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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee has stabilized medically and is ready for discharge from the hospital.  The enrollee does not require skilled nursing and/or skilled therapy services on a daily basis. She is 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 skilled nursing facility. The enrollee does not have any parental medication; complex wound care or nutrition given via a feeding tube.  She is medically stable without any acute exacerbations of chronic medical problems.  Her physical function is at or near her new baseline and she 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 the SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the inpatient hospital care provided from April 13, 2021, to April 18, 2021.  You asked the Plan to pay for the inpatient care. You say that these services were medically necessary and billed properly. The Plan denied your request. The Plan says these services were not billed correctly, as the submitted diagnosis of ileus, unspecified (K56.7) is not supported in the record.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. The 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 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 inpatient care. Our reviewer says that the submitted diagnosis of ileus, unspecified (K56.7) is not supported in the record. Our reviewer found that the provider assigned ICD 10-CM (International Classification of Diseases) code K56.7 (Ileus, unspecified) as an additional diagnosis. Following review, diagnosis code K56.7 was not supported as an additional diagnosis by the documentation in the medical record provided. Documentation regarding the diagnosis of ileus was found to be inconsistent and conflicting. A single Progress Note documented the diagnosis of ileus. All other Progress Notes stated the enrollee's diet was advanced and the enrollee was ambulating and passing flatus. The Discharge Summary noted the enrollee's diet was advanced with no nausea or vomiting and was passing flatus and having bowel movements. In this case, the ileus was only documented once and not further clarified in the Discharge Summary. The review has determined that the documentation submitted did not support diagnosis code K56.7 for Ileus, unspecified, and therefore, the information submitted by the provider is not corroborated by the enrollee's medical documentation.  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 inpatient care have not been met. Therefore, we decided that the Plan does not have to pay for the inpatient hospital care provided from April 13, 2021, to April 18, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve treatment with Lorazepam tablet.  You asked the Plan to pre-approve Lorazepam tablet. You say that the requested drug is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for self-administered drugs have not been met.  The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drug requested here is not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve treatment with Lorazepam tablet.   Benefits for Lorazepam tablet may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an additional level for facet joint interventions.  You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says additional areas are not medically necessary.  The Plan follows Medicare rules. Medicare rules say that facet joint interventions are only covered under certain medical indications. The file shows that three levels of treatment were requested. The Plan has agreed to pre-approve 2 levels. 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 additional requested level Our physician reviewer found that the guidelines state the enrollee cannot have three areas treated at the same time. Coverage of an additional third joint level is not supported. The review has determined that the service at issue in this case 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 requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve an additional level for facet joint interventions.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an all-lower extremity prostheses, energy storing foot (L5976).  You asked the Plan to pre-approve the K3 foot. You say that the enrollee has had these components in the past and they are no longer under warranty. They are necessary components of her prosthesis and you have included additional documentation to support that. The Plan denied your request. The Plan says the enrollee's current K3 foot was approved in November 2019 and is still under warranty.  The Plan must follow Medicare rules. Medicare rules say that Medicare cannot cover a replacement foot when the current foot is still under warranty.   We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the K3 foot have not been met. Therefore, we decided that the Plan does not have to pre-approve an all-lower extremity prostheses, energy storing foot (L5976).
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 this level of care is needed for the fastest recuperation. The Plan denied your request. The Plan says the denial of authorization for IRF care is correct.  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 enrollee's nursing, medical, and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the enrollee may require physical and/or occupational therapy, there is no documented need for an intensive rehabilitation therapy program. There is not a reasonable expectation that the enrollee will 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: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a cystourethroscopy provided on June 8, 2021.  You asked the Plan to waive the copayment for a cystourethroscopy. You say that the procedure was not successful, and you should not be responsible for 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 $200 copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers.   You have been asked to pay a $200 copayment for a cystourethroscopy. A cystourethroscopy falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 a cystourethroscopy provided on June 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve bone graft, mandible (21215), bone graft, nasal, maxillary or malar areas (21210), alveoloplasty, each quadrant x4 (41874) and impression and custom preparation, oral surgical splint x1 (21085).  You asked the Plan to pre-approve the dental services. You say that you are appealing the denial of the pre-authorization request. The enrollee has attempted conservative care which had failed. The Plan denied your request. The Plan says oral surgical splints are not covered when used to treat a dental condition.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the dental services when the services are medically necessary and reasonable.   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 dental services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation provided does not meet the criteria for coverage for the services indicated. As noted in the Medicare guidelines treatment of the supporting structures of the teeth are not covered.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental services have not been met. Therefore, we decided that the Plan does not have to pre-approve bone graft, mandible (21215), bone graft, nasal, maxillary or malar areas (21210), alveoloplasty, each quadrant x4 (41874) and impression and custom preparation, oral surgical splint x1 (21085).
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 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 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 enrollee's nursing, medical and rehabilitation needs does not require an acute 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, and an intensive rehabilitation therapy program. While the enrollee has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. There is not a reasonable expectation that this enrollee will 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: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.  You asked the Plan to pre-approve the SNF services. You say that SNF care is medically necessary. You say that the enrollee would benefit from the completion of rehabilitation to address decreased strength, impaired activities of daily living, and decreased mobility and endurance. You say that the enrollee is not safe to go home. The Plan denied your request. The Plan says the enrollee has not met the guidelines for coverage of SNF care.  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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral medications and had stable vital signs. The enrollee received physical therapy and occupational therapy in the acute hospital. The enrollee was at a contact guard to standby assist level with functional mobility including gait to 65 feet. The enrollee required varying assist with activities of daily living. There are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs, however they are not required on a daily basis. The enrollee does not meet the severity of illness or intensity of service criteria for an inpatient basis in a 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 the SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve compression stockings identified with code A6549.  You asked the Plan to pre-approve the compression stockings. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.  The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are noncovered because they do not meet the statutory definition of a surgical dressing.   Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6549.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve use of pembrolizumab (Keytruda).  You asked the Plan to pre-approve pembrolizumab. You say that the enrollee needs Keytruda and Inlyta. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because Keytruda for treatment of stage IV metastatic sarcomatoid renal cell carcinoma in combination with Imlyta after progression on Opdivo and Yervoy is not Food & Drug Administration (FDA) approved nor listed in information resources approved by Medicare.  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 pembrolizumab. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested use of pembrolizumab. Our physician reviewer found pembrolizumab is not Food & Drug Administration (FDA) approved for the enrollee's condition. The requested use is not supported by one of the major drug compendia or by clinical research appealing 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 pembrolizumab have not been met. Therefore, we decided that the Plan does not have to pre-approve use of pembrolizumab (Keytruda).
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.  You asked the Plan to pre-approve SNF services. You say that you are unable to live alone. The Plan denied your request. The Plan says that your records show that the services you require can safely be received at a different setting.  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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for SNF services.  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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.