Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Partially Favorable

We decided that the Plan has to waive the cost for the surgical supplies. We decided that the Plan does not have to waive the cost for the knee replacement, Part B drugs, x-ray, physical therapy, ultrasonic guidance for needle placement and self-administered drugs.

You asked the Plan to waive the cost for the knee replacement, Part B drugs, surgical supplies, x-ray, physical therapy, ultrasonic guidance for needle placement and self-administered drugs. You say that you are being charged for things that should have been covered through your knee surgery. The Plan says that the cost share applied correctly.

We decided that the Plan has to waive the cost for the surgical supplies.

The Plan billed you $514.01 for non-sterile supplies, sterile supplies, surgical supplies (unspecified), anchor/screw, and knee implant. These services are all considered surgical supplies provided during the outpatient surgical procedure. The Plan contract clearly says that you pay a $0 copayment for surgical supplies. Therefore, we decided the Plan has to waive the $514.01 coinsurance for the surgical supplies.

We also decided that the Plan does not have to waive the cost for the knee replacement, Part B drugs, x-ray, physical therapy, ultrasonic guidance for needle placement and self-administered drugs.

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 $50 copayment for outpatient surgery, 20% coinsurance for Medicare Part B covered chemotherapy drugs and other Part B covered drugs, a $10 copayment for x-rays and diagnostic procedures and tests and a $20 copayment for outpatient rehabilitation services. The Plan also does not pay for the self-administered drugs. Therefore, we decided that the Plan does not have to waive the cost for the knee replacement, Part B drugs, x-ray, physical therapy, ultrasonic guidance for needle placement and self-administered drugs.

Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.

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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home infusion therapy for Vancomycin.

You asked the Plan to pre-approve the requested services. You say that you are at risk for losing your leg. The Plan denied your request. The Plan says home skilled nursing is responsible to deliver and bill for this service.

The Plan must follow Medicare rules. The rules say that if an infusion drug is being received that is not identified as a "home infusion drug", then the professional services for the administration of the drug would remain covered under the Home Health benefit if the patient is eligible for home health services.

We looked at the file, and Medicare rules. The record shows that the enrollee is receiving Home Health services. The drug at issue is not identified by Medicare as a "home infusion drug". This means that the service is not separately covered and would remain covered under the home health benefit. 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 home infusion therapy for Vancomycin.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric care from September 24, 2021, forward.

You asked the Plan to pre-approve inpatient psychiatric care from September 24, 2021, forward. You say that the services at issue are medically necessary. The Plan denied your request. The Plan says the services at issue are not medically necessary.

The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve inpatient psychiatric care from
September 24, 2021, forward. Our reviewer says that you do not meet the criteria for acute inpatient mental
health treatment. Our physician reviewer found you did not require inpatient mental health treatment as you
were not a danger to yourself or others and did not have any delusions, auditory or visual hallucinations. It did
not appear that active treatment was taking place. It did not appear that the services for the dates in question
were reasonably expected or medically necessary to improve your condition or for the purpose of diagnosis.

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 psychiatric care from September 24, 2021, forward have not been met.
Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from September 24,
2021, forward.
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. The Plan denied your request. The Plan says the enrollee will not be able to tolerate 3 hours of therapy per day.
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 physician reviewer found that the enrollee was admitted to the acute care hospital for respiratory failure, sepsis, and small bowel obstruction. His medical problems are stable. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve oxygen (O2) concentrator and portable oxygen (O2) homefill system.

You asked the Plan to pre-approve oxygen (O2) concentrator and portable oxygen (O2) homefill system. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested items are not medically necessary.

The Plan must follow Medicare rules. The rules say that for patients with arterial PO2 at or above 60 mm Hg or arterial O2 saturation at or above 90%, there is a rebuttable presumption of non-coverage for home oxygen. 

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 oxygen (O2) concentrator and portable oxygen (O2) homefill system. Our reviewer says that the documentation does not support that the requested items are medically reasonable or necessary. Our physician reviewer found the enrollee has recurrent aspiration pneumonia and was discharged on oxygen after hospitalization for aspiration pneumonia in 2020. The current medical records do not include any pulse oximetry or arterial blood gas data that indicate a need for supplemental oxygen. There is one oximetry reading of 99%; it is unclear whether this is on room air or oxygen. Therefore, the enrollee does not meet criteria for the requested items. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of oxygen (O2) concentrator and portable oxygen (O2) homefill system have not been met. Therefore, we decided that the Plan does not have to pre-approve oxygen (O2) concentrator and portable oxygen (O2) homefill system.
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 will benefit from inpatient rehab due to her medical condition. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. There is 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 pre-approve the injections of a diagnostic or therapeutic agent, paravertebral facet joint with image guidance, of the lumbar or sacral (64493, 64494 and 64495).
You asked the Plan to pre-approve the injections. You say that the service is medically necessary. The Plan denied your request. The Plan says the notes do not show that your pain decreased by at least 80 percent.
The Plan follows Medicare rules. Medicare rules say that After the first diagnostic facet joint procedure, there must be a consistent positive response of at least 80% relief of primary (index) pain (with the duration of relief being consistent with the agent used) 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 injections. Our reviewer says that the service is not medically necessary. Our physician reviewer found the pain has had successful RFAs at the requested levels. It is not necessary to repeat MBB at the site of successful RFAs and there is a utilization limit of RFAs of two per rolling twelve-month period. 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 injections have not been met. Therefore, we decided that the Plan does not have to pre-approve the injections of a diagnostic or therapeutic agent, paravertebral facet joint with image guidance, of the lumbar or sacral (64493, 64494 and 64495).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance service, basic life support, emergency transport (A0429) provided on March 11, 2021.
You asked the Plan to pay for the ambulance service. You say that when you called 911 you asked for them to send the fire department. You also say that you had fallen and just needed help to get up. The Plan denied your request. The Plan says treatment provided by an ambulance without transportation is not covered by your plan benefits.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on March 11, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance service, basic life support, emergency transport (A0429) provided on March 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 is not medically necessary

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 your nursing, medical and rehabilitation needs do not require an
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program.

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 pre-approve Interspinous Implants.
You asked the Plan to pre-approve Interspinous Implants. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested 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 Interspinous Implants. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has back pain. Interspinous process devices remain experimental. More research is needed to show safety and efficacy of the devices. Therefore, the enrollee does not meet criteria for the requested 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 Interspinous Implants have not been met. Therefore, we decided that the Plan
does not have to pre-approve Interspinous Implants.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet joint injections.

You asked the Plan to pre-approve facet joint injections. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because the records do not indicate any conservative treatments other than oral steroids.

The Plan follows Medicare rules. Medicare rules state that facet joint interventions may be covered under certain clinical circumstances. 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 facet joint injections. Our reviewer says that the enrollee does not meet the Medicare criteria for these facet joint injections.

Our physician reviewer found there is no documentation showing that conservative management - such as
physical therapy - has been tried and failed for 3 months or more.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of facet joint injections have not been met. Therefore, we decided that the Plan
does not have to pre-approve facet joint injections.
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 requested use of this drug is not FDA-approved for the enrollee's diagnosis and
its use is not supported by one of the major drug compendia or clinical research.

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
drug is not medically necessary. Our physician reviewer found the requested use of this drug is not FDAapproved
for the enrollee's diagnosis and its use is not supported by one of the major drug compendia or
clinical research.

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: Lab
Decision: Favorable

We decided that the Plan has to pay for ConfirmMDx testing provided on December 17, 2020.
You asked the Plan to pay for genetic testing. You say that you are appealing with supporting records. The Plan denied your request. The Plan says that the denial of payment for this testing is correct, because screening services without a valid medical diagnosis related to the health of the patient are not a covered benefit.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The plan follows these rules. This testing was ordered by an in-network physician, who attested to the non-screening purposes of this testing. The file does not show that the plan provided notice that genetic testing would not be covered. Under Medicare rules, this means genetic testing is considered approved by the plan. Therefore, we decided that the Plan has to pay for ConfirmMDx testing provided on December 17, 2020.
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric care from September 28, 2021, forward.

You asked the Plan to pre-approve inpatient psychiatric care from September 28, 2021, forward. You say that the services at issue are medically necessary. The Plan denied your request. The Plan says the services at issue are not medically necessary.

The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve inpatient psychiatric care from September 28, 2021, forward. Our reviewer says that you do not meet the criteria for acute inpatient mental health treatment beyond the date in question of September 28, 2021, forward. Our physician reviewer found you did not require inpatient mental health treatment beyond September 28, 2021, as you were not a danger to yourself or others and did not have any delusions, auditory or visual hallucinations. It did not appear that active treatment was taking place beyond the date in question. It did not appear that the services for the dates in question were reasonably expected or medically necessary to improve your condition or for the purpose of diagnosis.

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 psychiatric care from September 28, 2021, forward have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from September 28, 2021, forward.
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 is not medically necessary.

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 documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program.

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.