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

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the enrollee's oxygen level has fallen after therapy and inpatient rehabilitation is recommended. The Plan denied your request. The Plan says the denial of authorization for SNF care 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 the enrollee does not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee does 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 skilled nursing facility (SNF) care.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve the percutaneous transcatheter closure of congenital interatrial communication (93580).
You asked the Plan to pre-approve the percutaneous transcatheter closure of congenital interatrial communication. You say that this request is medically necessary. The Plan denied your request. The Plan says that this is considered experimental and investigational in patients over 60 years of age.
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 percutaneous transcatheter closure of congenital interatrial communication. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found that the record indicates that the enrollee has an atrial septal defect and has had cryptogenic stroke. The enrollee has undergone a cardiac and neurologic work-up with joint decision making recommending the closure of the paten foramen ovale. The device is not contraindicated above the age of 60. The elements of the coverage criteria are satisfied. The provided records do not support the medical necessity and reasonableness, as defined by Medicare rules, of the requested service for the enrollee's condition. The elements of the coverage criteria are not satisfied. The requested service cannot be recommended. 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 percutaneous transcatheter closure of congenital interatrial communication have been met. Therefore, we decided that the Plan has to pre-approve the percutaneous transcatheter closure of congenital interatrial communication (93580).
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: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Udenyca. 
 
You asked the Plan to pre-approve Udenyca. The Plan denied your request. The Plan says the enrollee has not 
tried and failed Zarxio and Ziextenzo.  

Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications.

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 Udenyca. Our physician reviewer found 
that the enrollee has a diagnosis of malignant neoplasm of unspecified ovary. The Plan requires a trial of Zarxio 
or Ziextenzo before they will approve the requested drug. In this case, the enrollee has not tried and failed the 
required drugs. There is no documentation provided indicating that the Plan's required drugs likely be less 
effective or likely have adverse effects 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 Udenyca have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Udenyca.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of SNF care from October 15, 2021, forward.
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment in a SNF beyond the last covered date. The documentation does not reveal evidence of complex wound care, new enteral feedings, or other skilled nursing SNF need. Your functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment in a SNF. You do not require skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis" in a SNF. As a practical matter, you do not require the necessary services on an inpatient basis, in a SNF setting beyond the last covered date. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve continuation of SNF care from October 15, 2021, forward.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the immediate upper denture (D5130) provided on March 25, 2021.
You asked the Plan to pay for the denture. You say that you live on a fixed income and cannot afford this bill. The Plan denied your request. The Plan says you have already met and exceeded your benefit limit of $2,000. You are responsible for the costs that exceed this annual maximum.
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 will pay a maximum of $2,000 per year for eligible dental services. Though the Plan offers a dental benefit in excess of Medicare coverage, documentation shows that you have already met and exceeded the $2,000 annual limit. Therefore, we decided that the Plan does not have to pay for the immediate upper denture (D5130) provided on March 25, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient cataract surgery you had on 
June 8, 2021. 
 
You asked the Plan to waive the copayment for the outpatient cataract surgery. You say that you wanted to 
have both eyes done at the same time, but the provider refused.  You said that you shouldn't have to pay a 
second surgery copayment because of this. The Plan denied your request. The Plan says you were charged this 
copayment 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 $350 
copayment for outpatient surgery.  
 
You have been asked to pay a $350 copayment for the outpatient cataract surgery. This copayment applies 
regardless of why you had two separate surgeries. 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 outpatient cataract surgery you had on June 8, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapy services provided on January 18, 2019, through March 18, 2019.
You asked the Plan to pay for the therapy services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the medical records do not substantiate that a reassessment was done and there is no physician order for the number of therapy services rendered.
The Plan must follow Medicare rules. Medicare rules say that therapy services may be covered if a qualified therapist has completed the reassessment and objective measurement of the effectiveness of the therapy as it relates to the therapy goals. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the therapy services have not been met. Specifically, the record does not support that the criteria for the reassessment have been met. Additionally, the physician order indicates that one service per week was ordered. The record shows that the member received more services than what were ordered by the physician. Therefore, we decided that the Plan does not have to pay for the therapy services provided on January 18, 2019, through March 18, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the endodontist services provided on May 24, 2021.
You asked the Plan to pay for radiographic survey of the whole mouth (D0210) and comprehensive oral evaluation (D0150). You say that the provider should have requested the x-rays from your dentist. The Plan denied your request. The Plan says they will remove the frequency limitation denial, but you have now reached your annual maximum dental benefit.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is $1000 Annual Maximum Dental Benefit. The item or service you asked the Plan to pay for falls within the dental benefit MOOP. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $1000 Annual Maximum Dental Benefit. This MOOP had been met at the time the radiographic survey of the whole mouth (D0210) and comprehensive oral evaluation (D0150) claim was adjusted. Therefore, we decided that the Plan does not have to pay for the endodontist services provided on May 24, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does not meet criteria.
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 is receiving appropriate care at the present acute care hospital. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. 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 long term acute care hospital (LTACH) services.
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 is a good candidate for IRF care and cannot receive the same treatment at a lower level of care. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. The enrollee's ongoing skilled therapy and nursing needs can be provided at 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 that 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 documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the collection of venous blood by venipuncture services
provided to the enrollee from January 5, 2021.
You asked the Plan to pay for the collection of venous blood by venipuncture services. You say that you would
like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable
as billed.
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must
be completed for home health care services to be covered.
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that
Medicare rules for completing the claim for the collection of venous blood by venipuncture services have not
been met. Specifically, the documentation shows that this code needs to be billed with an additional code
(G0466, G0467, G0468, G0469, G0470 or G2025). Payment for this service cannot be made as billed.
Therefore, we decided that the Plan does not have to pay for the collection of venous blood by venipuncture
services provided to the enrollee from January 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve interventional endoscopic procedures EUS and/or EMR to be provided by an out-of-network provider.
You asked the Plan to pre-approve the out-of-network services. You say that the services are necessary. The Plan denied your request. The Plan says there is an in-network provider in your area and this in-network provider can give you the service you need. 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 interventional endoscopic procedures EUS and/or EMR to be provided by an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found at the current medical stability and lack of medical complexity, there is no need for physician supervision 3 times per week (at a minimum) for the ongoing management of any active or acute exacerbation of chronic medical conditions. Your rehab needs can be safely met in an alternate and low intensity setting such as in-home 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 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 pay for the compression stockings identified with code A6533 that
were issued on May 7, 2021.
You asked the Plan to pay for compression stockings. You say that the requested items are a medical necessity
for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met because the
requested items are not a benefit of Medicare or the Plan.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6533 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 pay for the compression
stockings identified with code A6533 that were issued on May 7, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric care from October 13, 2021, forward.
You asked the Plan to pre-approve inpatient psychiatric care from October 13, 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 October 13, 2021, forward. Our reviewer says that you do not meet the criteria for acute inpatient mental health treatment beyond the date in question of October 13, 2021, forward. Our physician reviewer found you do not require inpatient mental health treatment beyond October 13, 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 October 13, 2021, forward have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from October 13, 2021, forward.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power scooter.
You asked the Plan to pre-approve a power scooter. You say that you cannot do things outside of the house with your rolling walker. The Plan denied your request. The Plan says you do not need a power operated vehicle for use inside the home.
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. The scooter at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pre-approve a power scooter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve power wheelchair accessories.
You asked the Plan to pre-approve the requested items. The Plan denied your request. The Plan says the power options can be controlled using their own switches.
The Plan must follow Medicare rules. Medicare rules say that wheelchair options and accessories are only covered under certain medical indications. We looked at the file and Medicare rules. The records provided do not indicate that the approved power options cannot be operated using their own switches. Based on this information, we decided that Medicare rules for coverage of the requested items have not been met. Therefore, we decided that the Plan does not have to pre-approve power wheelchair accessories.