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

We decided that the Plan does not have to pre-approve Yervoy and Opdivo.
You asked the Plan to pre-approve Yervoy and Opdivo. You say that the use of these drugs is supported by the National Comprehensive Cancer Network's guidelines. The Plan denied your request. The Plan says these drugs are not medically necessary or supported by the National Comprehensive Cancer Network's guidelines.
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 Yervoy and Opdivo. Our reviewer says that the record does not support that Yervoy and Opdivo are medically reasonable and necessary or safe and effective for the member. Our physician reviewer found the literature shows that these drugs are approved for 1st line therapy in patients who have no received prior immunotherapy. This member has received prior immunotherapy in the last few months. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Yervoy and Opdivo have not been met. Therefore, we decided that the Plan does not have to pre-approve Yervoy and Opdivo.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided to the enrollee on August 15, 2019.
You asked the Plan to pay for the physician services. You say that since Hospice benefits were revoked before the date of service, the claim should be paid. The Plan denied your request. The Plan says Original Medicare covers physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. The enrollee ended Medicare Hospice benefits on August 8, 2019. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the physician services provided to the enrollee on August 15, 2019.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the breast cancer assay provided to the enrollee on September 12, 2019.
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. The Plan says that there was no authorization for these services.
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 testing. Our reviewer says that the services at issue in this case were not medically reasonable or necessary. Our physician reviewer found the NCCN Guidelines for breast cancer, Version 2.2020-February 05, 2020 states that the 21-gene assay (OncotypeDX ) is preferred for node-negative breast cancer, such as this enrollee has. Such testing has management implications. 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 testing have been met. Therefore, we decided that the Plan has to pay for the OncotopeDX breast cancer assay provided to the enrollee on September 12, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for Radiology services (73221) provided June 16, 2018
You asked the Plan to pay for the radiology services. You say that the claim was filed timely. The Plan denied your request. The Plan says the claim at issue is a duplicate that was submitted untimely of another claim, which was filed timely and has already been paid.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 must be filed no later than one calendar year after the date of service. The record shows that a claim for the radiology services was not filed until September 30, 2019. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for Radiology services (73221) provided June 16, 2018
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for four units of electroencephalographic (EEG) monitoring (95951) provided from June 14, 2019 to June 17, 2019.You asked the Plan to pay forfour units of EEG monitoring. You say that this should be covered.The Plan denied your request. The Plan says four units of this code are not supported by the medical records.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 95951 is monitoring for localization of cerebral seizure focus by cable or radio, 16 or more channel telemetry, combined electroencephalographic (EEG) and video recording and interpretation (eg, for presurgical localization), each 24 hours.We find that four units of CPT code 95951 is not supported in the medical record. Specifically, each unit of this code is 24 hours, and four units of this code total 96 hours. The records submitted show that only 78 hours were spent on this service. Based on this information, we decided that Medicare rules for coverage of four units of EEG monitoring have not been met.Therefore, we decided that the Plan does not have to pay forfour units of electroencephalographic (EEG) monitoring (95951) provided from June 14, 2019 to June 17, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services (CPT 99354) provided to the enrollee
on August 2, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request.
The Plan says CPT 99354 is an add-on code that was billed without an appropriate primary procedure.
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 99354 is "Prolonged evaluation and management or
psychotherapy service(s) (beyond the typical service time of the primary procedure) in the office or other
outpatient setting requiring direct patient contact beyond the usual service; first hour (List separately in
addition to code for office or other outpatient Evaluation and Management or psychotherapy service)."
We find that CPT code 99354 is not supported in the medical record. Specifically, this code cannot be billed
separately without a primary procedure. 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
psychotherapy services (CPT 99354) provided to the enrollee on August 2, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on July 10, 2019 by out of network provider, "the doctor".You asked the Plan to pay forphysician visit. You say that the nursing facility was responsible for obtaining prior authorization, which should cover any treatment by the provider.The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and the referring nursing facility is also out-of-network with the Plan.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 items/services at issue in this appeal. The Plan did not pre-approve the item/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 medical services provided on July 10, 2019 by out of network provider, "the doctor".
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee is at a safe level of function to discharge home.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 the admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 the admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Lumbar Vertiflex Interspinous Spacer (22869, 22870, and C1821).
You asked the Plan to pre-approve a Lumbar Vertiflex Interspinous Spacer (22869, 22870, and C1821). You say that the requested Lumbar Vertiflex Interspinous Spacer is medically necessary. The Plan denied your request. The Plan says the requested Lumbar Vertiflex Interspinous Spacer is 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 a Lumbar Vertiflex Interspinous Spacer (22869, 22870, and C1821). Our reviewer says that the requested Lumbar Vertiflex Interspinous Spacer is not medically necessary. Our physician reviewer found the enrollee is diagnosed with lumbar spinal stenosis with neurogenic claudication and lumbar radiculopathy. The requested device is considered experimental. More research is needed to show safety and efficacy. The requested Vertiflex is not medically reasonable or necessary 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 a Lumbar Vertiflex Interspinous Spacer (22869, 22870, and C1821) have not been met. Therefore, we decided that the Plan does not have to pre-approve a Lumbar Vertiflex Interspinous Spacer (22869, 22870, and C1821).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve carboplatin/paclitaxel with pembrolizumab for the enrollee.
You asked the Plan to pre-approve carboplatin/paclitaxel with pembrolizumab. You say that this treatment is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met.
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 carboplatin/paclitaxel with pembrolizumab. Our reviewer says that Medicare coverage criteria are not met. Our physician reviewer found the request is for carboplatin/paclitaxel with pembrolizumab for recurrent non-small cell lung cancer. The records show you previously received a course of carboplatin and paclitaxel with consolidation durvulamab completed November 2019. Treatment at this point would not be considered first line and he has received prior immunotherapy and presumably recurred while still on it or shortly thereafter. The recommended combination of carboplatin/paclitaxel with pembrolizumb is not first line in this case and is not considered a standard regimen. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of carboplatin/paclitaxel with pembrolizumab have not been met. Therefore, we decided that the Plan does not have to pre-approve carboplatin/paclitaxel with pembrolizumab for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Quetiapine Fumarate 25 MG tablets.

You asked the Plan to pre-approve Quetiapine Fumarate tablets. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says Quetiapine Fumarate tablets are not covered under the enrollee's Medicare Part B 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 Quetiapine Fumarate 25 MG tablets. 

Benefits for Quetiapine Fumarate tablets 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for dermatology services provided on June 13, 2019.
You asked the Plan to pay for dermatology services. You say that you attempted to obtain authorization as a geographical gap exception and are appealing with medical records. The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network with the Plan and the services were not urgent or emergent in nature.
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 dermatology services. Our reviewer says that these services do not meet the Medicare criteria for urgent out-of-area care. Our physician reviewer found the enrollee could have foreseen the need for these services prior to leaving the Plan's service area.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of dermatology services have not been met. Therefore, we decided that the Plan does not have to pay for dermatology services provided on June 13, 2019.
Appeal type: Outpatient Therapies
Decision: Favorable

We decided that the Plan has to pre-approveproton beam therapy.You asked the Plan to pre-approvethe therapy. You say that this is medically necessary.The Plan denied your request. The Plan says that there are insufficient clinical outcomes reported in the medical literature to allow conclusions to be made regarding the relative safety/efficacy of proton radiotherapy for the management of prostate cancer.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 therapy. Our reviewer says that the requested therapy is considered medically reasonable and necessary in this case. Our physician reviewer found the LCD criteria is met, since the target is in close proximity to the kidney, and that a clinically meaningful from the therapy is anticipated and plausible. For this case, the pelvic kidney presents an exceptional circumstance forwhich it would be highly plausible that proton therapy would have a clinically meaningful benefit over IMRT, as the kidney is very susceptible to radiation injury, the enrollee only has 1 kidney, and VMAT/IMRT is more apt to deliver low/moderate dose to the kidney which if reduced would lower the risks of renal toxicity.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 therapy have been met.Therefore, we decided that the Plan has to pre-approveproton beam therapy.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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitor.
You asked the Plan to pre-approve a therapeutic continuous glucose monitor. You say that because of a
medical condition the enrollee has severe dexterity issues. The Plan denied your request. The Plan says the
enrollee is not insulin treated and therefore criteria was not met.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered only when they
are medically reasonable and necessary and replace a blood glucose monitor.
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 a therapeutic continuous glucose
monitor. Our physician reviewer found the enrollee does not need increased home glucose monitoring that
requires a CGM. The enrollee has a medical condition but is not maintained on insulin therapy. The enrollee
does not require more than daily monitoring and the dexterity issues have not been quantified. The review has
determined that the documentation does not support that the enrollee's medical condition and dexterity issues
are severe enough as to make the use of a CGM medically reasonable and necessary as defined in the 1862
criteria cited in spite of usual coverage criteria requiring insulin use and multiple daily testing.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of a therapeutic continuous glucose monitor have not been met. Therefore, we
decided that the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitor.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network
provider.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your
request. The Plan says there are network providers available.
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 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 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
a referral to an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to the enrollee an out-of-network provider on October 8, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says non-emergent services rendered by non-participating providers in non-participating facilities require prior authorization as outlined in the enrollee's EOC.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 forthe medical services provided to the enrollee by an out-of-network provider on October 8, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay foran incisional biopsy of eyelid skin (67810) provided on August 1, 2019.You asked the Plan to pay forthe biopsy. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says the documentation submitted did not include documentation of incisional biopsy of eyelid skin including lid margin.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 67810 incisional biopsy of eyelid skin including lid margin.We asked our coder 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 biopsy. Our reviewer says that CPT code 67810 does not meet criteria for billing or reimbursement consideration. Our reviewer found the medical records provided do not include documentation of an incisional biopsy of eyelid including lid margin, therefore the procedure cannot be verified as being performed on August 1, 2019. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the biopsy have not been met.Therefore, we decided that the Plan does not have to pay foran incisional biopsy of eyelid skin (67810) provided on August 1, 2019.