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

We decided that the Plan does not have to pre-approve Pembrolizumab (Keytruda).
You asked the Plan to pre-approve Keytruda. The Plan denied your request.
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 physician reviewer found that Keytruda is approved for single-agent treatment of metastatic NSCLC in patients with tumors with PD-L1 expression (Tumor Proportion Score greater than or equal to 1%), as determined by an approved test, and with disease progression on or following platinum-containing chemotherapy. You were started on a clinical trial despite progression on prior immunotherapy. Your PD-L1 expression is less than 1%. Your stable disease may have been due to other medications, and you have not received a platinum. Therefore, the requested drug is not considered medically reasonable and 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 Keytruda have not been met. Therefore, we decided that the Plan does not have to pre-approve Pembrolizumab (Keytruda).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the urine testing rendered on October 25, 2019.You asked the Plan to pay for these services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure code 81025 is not supported.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.In this case, the CPT Code Manual definition of code 81045 is urine pregnancy test, by visual color comparison methods.We find that CPT code 81045 is not supported in the medical record. Specifically, the documentation does not support that a urine pregnancy test was performed. 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 pay for the urine testing rendered on October 25, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a coronectomy (D7251) of tooth #17.
You asked the Plan to pre-approve the coronectomy. You say that the enrollee is having frequent infections on tooth #17. You also say that these infections can be life threatening to the enrollee. The Plan denied your request. The Plan says this service is not covered by the enrollee's benefit plan under any circumstances.
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 coronectomy (D7251) of tooth #17
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xifaxan.You asked the Plan to pre-approve these services. You say that you disagree with the denial.The Plan denied your request. The Plan says self-administered drugs are not a covered benefit.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 Xifaxan.Benefits for these services 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the neck spine.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the records show that you had an incision and drainage on your left hand and had left hand swelling and numbness of the thumb. The physical findings show a healed incision on the left hand. There is no evidence in the records to suggest neck spine nerve root issues or other abnormalities related to the neck spine; therefore, the MRI is not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the neck spine.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve intradialytic parenteral nutrition (IDPN).
You asked the Plan to pre-approve IDPN. You say that the services are necessary. The Plan denied your
request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not been
met.
The Plan follows Medicare rules. Medicare rules say that in order to cover intradialytic parenteral nutrition
(IDPN), documentation must be clear and precise to verify that the beneficiary suffers from a permanently
impaired gastrointestinal tract and that there is insufficient absorption of nutrients to maintain adequate strength
and weight.
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 IDPN. Our reviewer says that the
service is not medically necessary. Our physician reviewer found based on the medical records presented the
intradialytic parenteral nutrition is not medically reasonable and necessary. You do not meet the criteria for
coverage.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IDPN have not been met. Therefore, we decided that the Plan does not have to
pre-approve intradialytic parenteral nutrition (IDPN).
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pay for the EGD provided to you on January 23, 2020.
You asked the Plan to pay for the EGD. The Plan denied your request. The Plan says that the EGD was not medically necessary.
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 pay for the EGD. Our reviewer says that the requested EGD is considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee presented to her provider with generalized, non-radiating, dull abdominal pain of several months duration, mild in intensity but worsened when eating greasy/fatty foods. The provided records support use of Advil PRN, but no acid suppression therapy. In evaluation, her provider performed an EGD on January 23, 2020. The enrollee met the following provided coverage criteria for the service under review: 1. Age >60, 2. Use of NSAID's, 3. Dyspepsia, 4. Symptom persistence. 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 EGD have been met. Therefore, we decided that the Plan has to pay for the EGD provided to you on January 23, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the total electric hospital bed rendered on November 19, 2019.
You asked the Plan to pay for these services. You say that you have a letter from your provider stating you meet the criteria. The Plan denied your request. The Plan says the item is not covered.
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered. While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers coverage for this item. Therefore, we decided that the Plan does not have to pay for the total electric hospital bed rendered on November 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

e decided that the Plan does not have to pre-approve physician's services to be provided by physician.You asked the Plan to pre-approve the physician's services. You say that you do not want to see the in-network female urologist because of the way you were treated.The Plan denied your request. The Plan says you must receive care from a network provider and in most cases, care received from an out-of-network provider will not be covered, except for emergency care or urgently needed services and needed medical care that Medicare requires the Plan to cover and the providers in the Plan's network cannot provide this care which must be prior authorized.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. ThePlan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services.Therefore, we decided that the Plan does not have to pre-approve physician's services to be provided by physician.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 99223, CPT 90836) provided on October 3, 2019.You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed codes cannot be verified.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.In this case, the CPT Code Manual definition of code 99223 is "Initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor or unit.". The CPT Code Manual Definition of code 90836 is "Psychotherapy, 45 minutes with patient when performed with an evaluation and management service (List separately in addition to the code for primary procedure)".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 pay for the services. Our reviewer says that the use of CPT codes 99223 and 90836 is not supported by the records provided. Our physician reviewer found that the documentation submitted does not support CPT 99223 level for comprehensive history, comprehensive exam and medical decision making of high complexity. The documentation submitted also does not support CPT 90836, that actual psychotherapy, 45 minutes took place. 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 not been met.Therefore, we decided that the Plan does not have to pay for the services (CPT 99223, CPT 90836) provided on October 3, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided September 7, 2019 to September 9, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that you believe that the denial for coverage for the inpatient admission is not justified. The Plan denied your request. The Plan says the records do not support an inpatient level of care and the enrollee could have been treated at a lower level of care.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 pay for acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found at the time of admission, it was not reasonable to expect that two midnights in the hospital would be required. The ED evaluation showed no life/limb threatening condition(s). The enrollee could have been safely monitored on observation status, before deciding if two midnights of acute care would be medically necessary. As is, the enrollee readily improved and no initially undetected issues were discovered. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided September 7, 2019 to September 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the immunology referral. You say that you would like reconsideration because your doctor recommended you see this out-of-network provider. The Plan denied your request. The Plan says you do not need to go to an out-of-network provider when services are available in the community.
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 the medical services to be provided by an out of network (OON) provider
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve removable foot orthotics.
You asked the Plan to pre-approve these services. You say that walking is difficult. The Plan denied your request. The Plan says the services are not covered.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve removable foot orthotics.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code S8426 and S8422.You asked the Plan to pre-approve the compression stockings. You say that you are required to wear these every single day for the rest of your life.The Plan denied your request. The Plan says you do not meet the criteria for coverage of the requested garments.The Plan must follow Medicare rules. Medicare rules say that compression stockings described by codes S8426 and S8422 are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that compression bandages and gradient compression wraps are covered only when they are used as dressings over a qualifying wound.The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you do not have a medical condition for which compression stockings can be covered or paid for by Medicare.Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code S8426 and S8422.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance services.
The enrollee asked the Plan to pay for the ambulance services. The enrollee said that on the date of service she fell but was uninjured. The enrollee stated that the nursing facility insisted that an ambulance be called. Since the enrollee was not hurt and her vital signs were fine, the enrollee stated that she declined transportation to the hospital to save money. The enrollee said that she could not afford the ambulance bill and had no power to tell the staff not to call for it. The Plan denied the enrollee's request. The Plan says these services are not a covered benefit.
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 November 26, 2019. 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 ambulance services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power mobility device.
You asked the Plan to pre-approve a power mobility device. You say that you need a power mobility device. The Plan denied your request. The Plan says the face-to-face documentation does not show you have problems with daily activities.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. The file does not show you have a mobility deficit that impairs your participation in MRADLs, or that you can safely operate the PMD being requested. The file shows your condition can be improved by a manual wheelchair. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a power mobility device.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the needle electromyography rendered on October 9, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 95861 is not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 95861 is needle electromyography; 2 extremities with or without related paraspinal areas. We find that CPT code 95861 is not supported in the medical record. Specifically, there is no documentation that needle electromyography of two extremities was performed. 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 pay for the needle electromyography rendered on October 9, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a diagnostic mammogram (77066) provided October 1, 2019.
You asked the Plan to waive the copayment for the mammogram. You say that the copayment should be waived. The Plan denied your request. The Plan says the correct copayment was applied.
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 $125 copayment for Radiological diagnostic services. You have been asked to pay a $125 copayment for the mammogram. The diagnostic mammogram falls within the Radiological diagnostic services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a diagnostic mammogram (77066) provided October 1, 2019.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ILUMYA.You asked the Plan to pre-approve these services. You say that the services are medically necessary.The Plan denied your request. The Plan says the services are not medically necessary.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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has a diagnosis of psoriasis vulgaris. He has not tried and failed the Plan's required drugs of REMICADE or INFLECTRA and STELARA. The records do not show that the required drugs would be less effective or contraindicated; therefore, ILUMYA is not reasonable or 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 these services have not been met.Therefore, we decided that the Plan does not have to pre-approve ILUMYA.