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

We decided that the Plan has to pre-approve transthoracic echocardiography (TTE) testing for the enrollee.
You asked the Plan to pre-approve the requested services. You say that the enrollee has an electrical impulse problem, and it has been over 10 years since his pacemaker was implanted. The Plan denied your request. The Plan says that there is no documentation to support the requested testing.
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 requested services. Our physician reviewer found that the enrollee has a history of longstanding hypertension, which is documented in the visit notes of January 29, 2020. He is being treated with long acting propranolol for this. There is also a plan to replace his end of life pacemaker and concern for lead fracture in the atrial lead. The enrollee has had no ventricular assessment by echocardiography in approximately 10 years as well. Longstanding hypertension to assess for hypertensive heart disease and left ventricular hypertrophy (LVH) is an indication for an echocardiography, especially when there has been no prior study in over a decade, which could then lead to more intensive blood pressure management if there is evidence of significant LVH. In addition, assessment of the pacer leads (the endocardial placement or movement of the leads, possible lead fracture, assessment of the extent of fibrosis of tissue at the lead contact points) is also a reasonable indication for repeat echo assessment prior to a planned pacer revision where lead replacement or lead explanation is planned, and when there is also a concern for the integrity of the pacer leads, as there is in this instance. Both these clinical indications are reasonable and medically necessary for cardiac assessment by transthoracic echocardiography. 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 been met. Therefore, we decided that the Plan has to pre-approve transthoracic echocardiography (TTE) testing.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve medical services to be provided by an out-of-network
(OON) provider.
You asked the Plan to pre-approve the services. The Plan denied your request. The Plan says the services are
available in-network.
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 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 medical
services to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider from May 21, 2019, to May 28, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 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 pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider from May 21, 2019, to May 28, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (T1019) provided to the enrollee on July 1,
2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not a Medicare
covered service.
The Plan must follow Medicare rules. Medicare rules say that a status indicator of "I" under the Physician Fee
Schedule indicates that the code in question is not valid for Medicare purposes.
We looked at the file and Medicare rules. Code T1019 is assigned a status indicator of "I" under the Physician
Fee Schedule, which means that this code is not valid for Medicare purposes. Medicare uses another code for
reporting of, and payment for, these services. 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 (T1019) provided to the enrollee on July 1, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered to the enrollee on June 21, 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 there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a
physician.
We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation.
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 drug testing rendered to the enrollee on June 21,
2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on March 27, 2019.You asked the Plan to pay forthe laboratory services. 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.The Plan must follow Medicare rules. Medicare rules say that a physician order is not required to be signed, however, the physician must clearly document, in the medical record, his or her intent that the test be performed.We looked at the file and Medicare rules. We find that payment for the lab services is not supported in the medical record. We find that the issue of intent is not clear. There are no medical records in the case file in regards to the physician's intent that the test be performed prior to services taking place.Therefore, we decided that the Plandoes not have to pay forthe laboratory services provided on March 27, 2019
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve kidney transplant evaluation.
You asked the Plan to pre-approve kidney transplant evaluation. You say that this evaluation is medically necessary. The Plan denied your request. The Plan says that Medicare coverage criteria are not met.
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 kidney transplant evaluation. Our reviewer says that the requested evaluation is considered medically reasonable and necessary in this case. Our physician reviewer found you have a diagnosis of ESRD and type 2 diabetes. Your diabetes is reasonably well controlled. The transplant itself if offered is a decision of the individual transplant centers. Some patients are denied by some centers and accepted by others depending on the review of each enrollee. There is nothing in records provided that would eliminate the enrollee from being sent for evaluation at this time. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of kidney transplant evaluation have been met. Therefore, we decided that the Plan has to pre-approve kidney transplant evaluation.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve low dose computed tomography (LDCT) for lung cancer screening for the enrollee.

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 enrollee does not meet the criteria for coverage.

The Plan must follow Medicare rules. Medicare rules say that LDCT for lung cancer screening is covered for beneficiaries aged 55 to 77 years. 

We looked at the file and Medicare rules. The file shows that the enrollee is 53 years old. 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 low dose computed tomography (LDCT) for lung cancer screening for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient acute care, and does not require transfer to LTACH.
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 long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not provide clinical services that are materially different than those of short term acute
care hospitals. In this case, ongoing care needs include intravenous antibiotics, wound and wound vacuum care, surveillance laboratory studies, and therapy services. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Udenyca for the enrollee.
You asked the Plan to pre-approve Udenyca. You say that it's getting harder for the enrollee to breathe. The Plan denied your request. The Plan says that the enrollee is not neutropenic, and is not receiving myelosuppressive anti-cancer chemotherapy.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 Udenyca. Our physician reviewer found that the enrollee has advanced oropharyngeal squamous cell carcinoma. The enrollee is considered at high risk for neutropenic fever. The enrollee has a likelihood of a greater than or equal to 20% risk based on his age, prior chemotherapy, and a current regimen with carboplatin and 5-FU. The use of peg-filgastrim/Udenyca is likely to decrease this risk. Therefore, the service is reasonable and 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 Udenyca have been met. Therefore, we decided that the Plan has to pre-approve Udenyca 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: 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 medical records. The Plan denied your request. The Plan says the denial of authorization for these services is correct, because with previous injections the enrollee only received 30% to 40% pain relief and Medicare guidelines require greater than 80% pain relief to justify repeat injections.
The Plan follows Medicare rules. Medicare rules say that a second set of medial branch blocks is only allowed if documentation indicates that the first set of medial branch blocks produced at least 80% relief of pain. 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 the requested facet joint injections. Our physician reviewer found the enrollee failed to achieve the standard degree of 80% pain relief with prior injections, therefore this is a negative result and the medial branch block should not be repeated. 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral for spine surgery.
You asked the Plan to pre-approve these services. You say that your spine went from 70 to 90 percent curved. The Plan denied your request. The Plan says the 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the submitted records do nit show that the criteria for revision spinal deformity surgery are met. There is no documentation of severe curve progression. The records do not show that you have tried and failed conservative measures for back pain. There are no red flags for surgery. The spine surgery is therefore 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 a referral for spine surgery.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the intravenous therapy, therapeutic injection, 2 injections of ferric carboxymaltose provided from July 17, 2019 to July 24, 2019.
You asked the Plan to pay for the inpatient hospital services. You say that you spoke to a plan representative who advised they would fax over the authorization form. You say that you had not received a form as of July 24, 2019 and called the enrollee's plan again. You say that you were advised again that the form would be faxed to you. The Plan denied your request. The Plan says authorization was not obtained before the services were provided to the enrollee. The Plan says the provider is out of the Plan's service area. The Plan also says the services were not urgent or emergent.
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and pre-approved care.
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 inpatient hospital services. Our reviewer says that the service is not medically necessary. Our physician reviewer found based on the provided documentation, there is no indication that the services provided were 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 out of area inpatient hospital services have not been met. Therefore, we decided that the Plan does not have to pay for the intravenous therapy, therapeutic injection, 2 injections of ferric carboxymaltose provided from July 17, 2019 to July 24, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not haveto pre-approve transthoracic echocardiogram with doppler complete for the enrollee.You asked the Planto pre-approvethe echocardiogram. You say that this is medically necessary.The Plandenied your request. The Plansaysthere is no documentation provided that shows episodes of syncope.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 fileand apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the echocardiogram. Our reviewer says that the requested echocardiogram is not considered medically reasonable and necessary in this case. Ourphysician reviewer found the enrollee has some cardiac risk but no documented cardiac symptoms, no cardiac physical exam abnormalities and no electrocardiographic abnormalities. His symptoms do not have documented features concerning for a cardiac cause and there are no palpitations or syncope reported. In this circumstance the documentation does not support the medical necessity for an echocardiogram. Coverage criteria are not met since there are no documented covered indications for the procedure.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 echocardiogram have not been met.Therefore, we decided that the Plandoes not haveto pre-approvetransthoracic echocardiogram with doppler complete for the enrollee.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay forthe Outpatient Mental Health Services (90837) provided on September 10, 2019.You asked the Plan to pay forthe Outpatient Mental Health Services. You say that the services were medically necessary and you are a network provider.The Plan denied your request. The Plan says the services were not preauthorized and the provider is not contracted for Medicare lines of business.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay forthe Outpatient Mental Health Services (90837) provided on September 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve medial branch blocks (MBBs) for the enrollee.
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.
The Plan must follow Medicare rules. Medicare rules say that MBBs are covered when specific criteria are met.
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 chronic low back pain
and underwent intra-articular facet joint injection and achieved only 20 percent pain relief. She did not achieve
the necessary degree of pain from the intra-articular pain relief. The requested diagnostic MBB is therefore 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 medial branch blocks (MBBs) for the enrollee.