Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of inpatient psychiatric care from December 29, 2021, forward.
You asked the Plan to pre-approve continued inpatient psychiatric care. You say that the enrollee requires additional inpatient psychiatric care, and feels she cannot take proper care of herself if she goes home at this time. The Plan denied your request. The Plan says as of December 29, 2021, psychiatric care at the acute inpatient level is no longer medically necessary for this enrollee.
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 continued inpatient psychiatric care. Our reviewer says that the health plan's denial of continued psychiatric care at the inpatient level appears appropriate in this case. Our physician reviewer found that the enrollee was admitted to the acute inpatient psychiatric hospitalization on December 23, 2021, with Major Depressive Disorder, Recurrent, Severe without Psychotic Features, Schizoaffective Disorder, Borderline Personality Disorder and Anxiety Disorder. Based upon review of the records provided, it was not expected this enrollee would improve in a reasonable period of time for the dates in question as she did not have suicidal or homicidal ideation noted and denied any auditory or visual hallucinations. The patient was compliant with treatment while not showing any acute threats to safety. It did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the dates in question as she did not have dangerousness to self or others but was compliant with her treatment. It did not appear that active treatment was taking place beyond the date in question. It did not appear that the services were reasonably expected to improve the enrollee's condition or for the purpose of diagnosis beyond the date in question. Based upon the records provided, the enrollee does not meet the criteria for inpatient psychiatric care from December 29, 2021, forward. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued inpatient psychiatric care have not been met. Therefore, we decided that the Plan does not have to pre-approve continuation of inpatient psychiatric care from December 29, 2021, forward.
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 a SNF is the best course of treatment. The Plan denied your request. The Plan says the guidelines for coverage of SNF care have not been met.
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 there is no documentation that the enrollee requires skilled nursing services to safely and effectively provide medically necessary and reasonable treatment. The enrollee does require skilled therapy services, but not on a daily basis. The enrollee does not require the services on an inpatient basis, only in a skilled nursing facility setting. Services in the home with home health care or in a long-term care facility on a part time basis appear appropriate in this case. 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.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a cerebral perfusion analysis.

You asked the Plan to pre-approve the requested services. You say that the CT perfusion will assess relative cerebral blood flow and transit times. The Plan denied your request. The Plan says the study is not being used in the setting of acute ischemia stroke.

The Plan must follow Medicare rules. Medicare rules say that CTP services are only covered under certain medical indications.

The file shows that computed tomography cerebral perfusion analysis (CTP) services were requested. 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 requested services. Our physician reviewer found that per coverage criteria, the requested service is only covered for use to aid in selection for endovascular mechanical thrombectomy. The enrollee had not been referred for a CTP study in the acute setting. Nor is this for evaluation of a possible stroke. This would not represent an indication for which this requested procedure is generally accepted for use nor would it reflect the generally accepted standards of care. In as much, the requested services would not be 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 requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve a cerebral perfusion analysis.
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 the records provided support the need for SNF care. The Plan denied your request. The Plan says the continued admission in a SNF does not meet the requirements for approval. The Plan says that SNF care is not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no skilled nursing service needs. There are no skilled therapy service needs. The enrollee does not require the services on an inpatient basis, only in a skilled nursing facility setting. Services in the home with home health care and a private duty caregiver or in a long-term care facility on a part time basis as needed appear appropriate in this case. 

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.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve stereotactic body radiation therapy (SBRT) for the enrollee.
You asked the Plan to pre-approve the services. You say that this is needed to treat a diagnosis of ventricular tachycardia. The Plan denied your request. The Plan says that this is not a standard of treatment for refractory ventricular tachycardia.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found from a multidisciplinary discussion, no other treatment options are available to this patient and SBRT was recommended. The main issue with this case is whether or not the published data to date are sufficient to consider it an acceptable, non-investigational standard of care. SBRT for ventricular tachycardia is a new approach, and further technical refinement and outcome studies are needed to optimize treatment and better understand those factors that can affect outcomes. Yet, the treatment has been shown to be effective using current technology and the published data to date are compelling that the treatment is safe and effective, particularly in a group of patients who have exhausted all other standard options. The need for better refinement of treatment and more outcome data apply to much of what is done in radiotherapy. In the absence of other standard treatment options, and based on data published to date showing SBRT is a safe and effective treatment, SBRT can considered an accepted standard of care for patients with treatment resistant ventricular tachycardia. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pre-approve stereotactic body radiation therapy (SBRT) 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: Favorable

We decided that the Plan has to pre-approve treatment with Reblozyl (J0896).

You asked the Plan to pre-approve Reblozyl. You say that the requested treatment is a medical necessity for the enrollee. The Plan denied your request. The Plan says that the requested drug has been prescribed for an off-label and medically unsupported use.

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 Reblozyl. Our reviewer says that the requested treatment is medically reasonable and necessary in this case. Our physician reviewer found that the requested use of Reblozyl is FDA-approved for the enrollee's diagnosis. The FDA has approved the requested drug for the treatment of anemia failing an erythropoiesis-stimulating agent and requiring 2 or more red blood cell (RBC) units over 8 weeks in adults with very low- to intermediate-risk myelodysplastic syndromes with ring sideroblasts (MDS-RS) or with myelodysplastic/myeloproliferative neoplasm with ring sideroblasts and thrombocytosis (MDS/MPN-RS-T). The documentation supports that the requested drug is safe and effective and otherwise reasonable and necessary for the 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 Reblozyl have been met. Therefore, we decided that the Plan has to pre-approve treatment with Reblozyl (J0896).

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 Lamotrigine.

You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your request. The Plan says that this is not covered under Part B.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Lamotrigine.

Benefits for this drug 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an inversion/eversion correction device (A9285).
You asked the Plan to pre-approve an inversion table. You say that your provider okayed the inversion table for
you and you are requesting coverage. The Plan denied your request. The Plan says an inversion table is
considered experimental, investigational or unproven and is not a standard treatment for neck and back spine
abnormality related pain.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered. The rules also say that experimental and investigational devices are not covered.
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of an inversion table have not been met. Therefore, we decided that the Plan does not have to preapprove
an inversion/eversion correction device (A9285).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda and Capecitabine for the enrollee.
You asked the Plan to pre-approve Keytruda and Capecitabine. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says that these drugs are not being prescribed for a supported medically-accepted indication.
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 and Capecitabine. Our reviewer says that Keytruda and Capecitabine are not medically reasonable and necessary for the enrollee. Keytruda and Capecitabine are not FDA-approved for the enrollee's diagnosis in combination. The use of Keytruda and Capecitabine are 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 the enrollee's condition does not meet criteria for coverage of these 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 Keytruda and Capecitabine have not been met. Therefore, we decided that the Plan does not have to pre-approve Keytruda and Capecitabine for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an L5-S1 Laminectomy with Coflex device placement for the enrollee.
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that a Coflex is not a standard treatment for foraminal stenosis.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Current evidence based medical guideline and peer reviewed literature do not fully support the spinal decompression device procedure over the 'gold standard' of lumbar laminectomy. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of this device for this enrollee's medical condition. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve an L5-S1 Laminectomy with Coflex device placement for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on April 9, 2021.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says there is no evidence of an established relationship between the member and the ordering physician.
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a physician who has furnished a consultation or treats an enrollee for a specific medical problem. The file does not contain documentation of an established relationship between the enrollee and the ordering provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this testing have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on April 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the myoelectric power enhanced upper extremity orthotic device (L8702).
You asked the Plan to pre-approve the orthotic device. You say that you are requesting a prior authorization for a MyoPro 2 Motion G for treatment of her left upper extremity partial paralysis. The enrollee has tried and failed conventional therapies and hand surgery. The Plan denied your request. The Plan says this item is considered experimental and investigational. There is insufficient evidence that shows the safety and/or success of this treatment.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the orthotic device have not been met. Therefore, we decided that the Plan does not have to pre-approve the myoelectric power enhanced upper extremity orthotic device (L8702).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extraction (D7140) provided on August 4, 2021.
You asked the Plan to pay for the dental service. You say that you were advised by a plan representative that extractions are covered, and the dentist was in network. The Plan denied your request. The Plan says extractions are not listed as a covered service.
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 extraction is not among those covered under this benefit. Additionally, the record shows that there were no called made to the Plan prior to
the date of service. Therefore, we decided that the Plan does not have to pay for the extraction (D7140) provided on August 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for (2) oral surgery, alveoloplasty in conjunction with extractions (D7311) provided on August 3, 2021.

You asked the Plan to pay for alveoloplasty in conjunction with extractions. You say that you were misinformed on the Plan's $2,000 limit, the limit on extractions and you were told dental work was covered 100%. You also say you are receiving a bill and you are on a limited income and do not have the funds for your dentures. The Plan denied your request. The Plan says reimbursement was already issued for two oral surgery services; therefore, the frequency limitation has been exceeded.

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 2 oral surgery procedure codes per calendar year.

We looked at the file and Medicare rules. The EOC confirms you receive 2 oral surgery procedure codes per calendar year. The records show you received 2 oral surgery procedures on July 13, 2021; therefore, you have exceeded your limitation for this service. Based on this information, we decided that the Plan's rules for coverage of alveoloplasty in conjunction with extractions have not been met. Therefore, we decided that the Plan does not have to pay for (2) oral surgery, alveoloplasty in conjunction with extractions (D7311) provided on August 3, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (G0483) provided on March 11, 2021.
You asked the Plan to pay for code G0483. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We looked at the file and Medicare rules. In this case, the claim was billed with an incorrect place of service (POS) code per Medicare guidelines. The records show that the specimen was obtained in an office setting.
Therefore, we decided that the Plan does not have to pay for the laboratory services (G0483) provided on March 11, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the sleep study (95811) provided on July 2, 2021.
You asked the Plan to waive the copayment for the sleep study. You say that you are dissatisfied with this provider. The Plan denied your request. The Plan says this claim was processed correctly, and your copayment was assessed in accordance with your contract. Your grievance is being addressed as a separate matter
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 a facility-based sleep study. You have been asked to pay a $50 copayment for the facility-based sleep study. 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 the sleep study (95811) provided on July 2, 2021.