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

We decided that the Plan has to pre-approve skilled nursing facility (SNF) services for the enrollee.
You asked the Plan to pre-approve SNF services. You say that the enrollee needs assistance with daily function
and needs focused SNF care as part of his recovery. The Plan denied your request. The Plan says that that the
patient has no current skilled nursing needs, and no pain control issues that would require skilled 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 SNF services. Our reviewer says that
SNF services are medically necessary and reasonable for the enrollee. The enrollee has reportedly been
admitted to the hospital three times in two months. The health plan summary cites records from the third
hospitalization and concludes that these records show that the enrollee does not require SNF services. While
records from the second hospitalization have been submitted for review, records from the third hospitalization
have not been submitted for review. As such, the health plan has failed to support its argument. Our physician
reviewer found that the enrollee's condition meets 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 been met. The Plan must continue coverage for the SNF
skilled service until such time as the enrollee no longer needs the service and proper notice has been issued, or
the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled
nursing facility (SNF) services for the enrollee.
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: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Menactra.  You asked the Plan to pre-approve Menactra. The Plan denied your request. The Plan says this drug is not covered for the enrollee's condition by the Medicare Part B plan.  The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill.  In this case, we have confirmed that the requested medication will be dispensed by a pharmacy. Since the medication does not represent an expense to the physician and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that the Plan does not have to pre-approve Menactra.   Benefits for Menactra 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: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Keytruda.  You asked the Plan to pre-approve Keytruda. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says that the clinical value and effectiveness of Keytruda as single agent first-line systemic therapy for the treatment of advanced or recurrent squamous cell vulvar carcinoma has not been demonstrated in the peer-reviewed literature.  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 Keytruda is not medically reasonable and necessary. Keytruda is not FDA-approved for your diagnosis. The use of Keytruda is not supported by one of the major drug compendia or by clinical research that appears in a Centers for Medicare & Medicaid Services approved medical journal. Our physician reviewer found that your condition does not meet Medicare criteria for Keytruda.  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.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the Intracept procedure.  You asked the Plan to pre-approve Intracept. You say that the Intracept procedure is medically reasonable and necessary for the enrollee. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because there is insufficient evidence in the form of high-quality peer-reviewed medical literature to support the safety and efficacy of the Intracept procedure.  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 Intracept. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this procedure is experimental/investigational.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Intracept have not been met. Therefore, we decided that the Plan does not have to pre-approve the Intracept procedure.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the assistant surgery services provided on January 19, 2021.  You asked the Plan to pay for the services. The Plan denied your request. The Plan says this type of provider is not payable for these services.  The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the procedure is covered for an assistant and the person who assists the surgery bears the designation of a physician, PA, NP, or CNS.  In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of practitioners. Therefore, we decided that the Plan does not have to pay for the assistant surgery services provided on January 19, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve arthrodesis, SI joint, percutaneous or minimally invasive (indirect visualization), with image guidance, includes obtaining bone graft when performed, and placement of transfixing device (CPT code 27279-RT), for the enrollee.  You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your request. The Plan says the clinical value and effectiveness of a minimally invasive percutaneous SI fusion in the setting of multifactorial low back pain, radiculopathy, and bilateral SI joint pain have not been demonstrated in the peer-reviewed literature.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the service. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found criteria not met. The records show the enrollee has multilevel degenerative low back pain. The physical therapy note indicates back and radicular leg symptoms. There is no documented SI joint instability, fracture, or lesion. SI joint fusion not medically needed.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the service have not been met. Therefore, we decided that the Plan does not have to pre-approve arthrodesis, SI joint, percutaneous or minimally invasive (indirect visualization), with image guidance, includes obtaining bone graft when performed, and placement of transfixing device (CPT code 27279-RT), for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a core buildup (D2950) provided by a participating provider.  You asked the Plan to pre-approve a core buildup. You say that you would like approval to provide these services. The Plan denied your request. The Plan says the requested dental service is not a covered benefit.  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 a core buildup (D2950) provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve deep sedation/general anesthesia (D9222 and D9223) provided by an out-of-network provider.  You asked the Plan to pre-approve deep sedation/general anesthesia. You say that you would like the Plan to approve and pay for these dental services. The Plan denied your request. The Plan says the requested dental services are not a covered benefit.  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 deep sedation/general anesthesia (D9222 and D9223) provided by an out-of-network provider.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for an ultrasound (76770) provided on February 3, 2021.  You asked the Plan to waive the coinsurance for an ultrasound. You say that you shouldn't have to pay. The Plan denied your request. The Plan says the cost share was applied 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 a 20% coinsurance for outpatient diagnostic tests.   You have been asked to pay a 20% coinsurance for an ultrasound. The service at issue falls within the outpatient diagnostic tests 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 coinsurance for an ultrasound (76770) provided on February 3, 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 enrollee would benefit from intensive rehab services and is expected to return home with a higher level of function following IRF care. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. The therapy required for this enrollee is not therapy that is uniquely provided in an IRF. The enrollee does not have complex nursing or medical needs and can be treated in a lower level of care.  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 with the enrollee's current medical stability and lack of documented medical complexity, there is no need for physician supervision at least three times per week for the ongoing management of any active or acute exacerbations of chronic medical conditions. There are no acute rehab nursing needs. Based upon the enrollee's current level of function, they do not require intensive therapies, consisting of at least three hours of therapy per day at least five days per week with a multidisciplinary approach to daily therapy. IRF admission is not medically necessary. While the enrollee would benefit from physical and occupational therapies, these rehab needs can be safely met in an alternate and lower intensity 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 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve low dose computed tomography (LDCT) for lung cancer screening.

You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your request. The Plan says this request cannot be approved.

The Plan must follow Medicare rules. Medicare rules say that low dose CT scans for lung cancer screening are only covered for enrollees between 55 and 77 years old. 

Your age - 80 years old - is outside of the covered age range for this request. Based on this information, we decided that Medicare rules for coverage of the scan have not been met. Therefore, we decided that the Plan does not have to pre-approve low dose computed tomography (LDCT) for lung cancer screening.
Appeal type: SNF
Decision: Favorable

 We decided that the Plan has to pre-approve skilled nursing facility (SNF) services.  You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that that your rehabilitation needs 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 SNF services are medically reasonable and necessary. You require skilled nursing services to safely and effectively provide medically necessary and reasonable treatment. You have a new percutaneous gastrostomy feeding tube due to severe dysphagia and appear to be receiving all of your nutrition via the feeding tube. You require skilled therapy services to safely and effectively provide medically necessary and reasonable treatment. Skilled nursing services are required for the care and management of the new feeding tube. You do require the services on an inpatient basis, in a skilled nursing facility setting due to the daily nursing needs. Our physician reviewer found that your condition meets 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 been met. The Plan must continue coverage for the SNF skilled service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing facility (SNF) services.   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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office visit (99213) rendered by the out-of-network (OON) provider on June 10, 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 office visit (99213) rendered by the out-of-network (OON) provider on June 10, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve LTACH services.  You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan denied your request. The Plan says your request is not medically necessary because the enrollee's records do not support that the enrollee has completed their full course in the hospital.  The Plan states it is not medically necessary for transfer of care to an LTACH, as the enrollee is receiving appropriate care in the acute care hospital.  The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.  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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee appears to be more stable but still requires weaning at the current acute care setting. The enrollee does not require services at the LTACH that are not already available at the current facility. There are no services at the LTACH that the enrollee requires that are not already available and covered at the current facility. LTACH transfer will be considered not medically necessary as it would not be clinically advantageous. Transfer to a lower level of care when treatment has completed and more weaning attempts are noted.  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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve LTACH services.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a bioimpedance spectroscopy (BIS) (93702).  You asked the Plan to pre-approve the BIS. You say that the BIS assessment is necessary for the enrollee due to her diagnosis of invasive ductal carcinoma right breast. You also say that BIS is a Medicare covered service. The Plan denied your request. The Plan says this service is considered experimental, investigational, and unproven for the assessment of lymphedema.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the bioimpedance spectroscopy (BIS). Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the BIS (93702) was requested for extracellular fluid analysis for lymphedema assessment as the enrollee has had chemotherapy and was reported to be a higher risk for lymphedema. Our reviewer found that the current evidence does not support the use of this test over standard methods for lymphedema assessment. Our physician reviewer also found that without sufficient support made or available for this request, the BIS will be considered not 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 the BIS have not been met. Therefore, we decided that the Plan does not have to pre-approve a bioimpedance spectroscopy (BIS) (93702).
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve imaging services (CPT code(s): 74230, 92611, 74240, 99204) to be provided by an out-of-network provider.  You asked the Plan to pre-approve the services. You say that this is an enrollee under your care who currently cannot safely travel to an outpatient facility for a modified barium swallow test. You state this enrollee is dependent for mobility and is transferred via hoyer lift to a reclining wheelchair. The Plan denied your request. The Plan says the services can be performed by an in-network provider.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.  The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve imaging services (CPT code(s): 74230, 92611, 74240, 99204) to be provided by an out-of-network provider.
Appeal type: Other
Decision: Unfavorable

 We decided that the Plan does not have to waive the $35 copayment for specialist services provided on June 23, 2021.  You asked the Plan to waive this copayment. You say that you do not believe this copayment is correct. The Plan denied your request. The Plan says this copayment was charged based on the services 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 $35 copayment for vision specialist services. 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 $35 copayment for specialist services provided on June 23, 2021.