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

We decided that the Plan has to pay for drug testing services (HCPCS G0483) provided to the enrollee on August 12, 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 that the documentation submitted did not include a physician order/lab requisition or medical records stating exactly what tests are to be performed.
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 is "Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed." 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 services at issue in this case were not supported by the medical records. Our physician reviewer found there is a signed order acknowledging, and the order is itemized. This is sufficient documentation of acknowledgement of the code in question We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for drug testing services (HCPCS G0483) provided to the enrollee on August 12, 2019.
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 pay for genetic testing services provided to the enrollee on February 12, 2020.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says Medicare Guidance says Comprehensive Genomic Profile (CGP) testing Guardant-360 requires use of CPT 81479, and the appropriate DEX Z identifier entered adjacent in the comment narrative field.
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 claim is missing the main code and identifier required by Medicare. Based on this information, we decided that Medicare rules for coverage of this claim have not been met Therefore, we decided that the Plan does not have to pay for genetic testing services provided to the enrollee on February 12, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia (J0897).
You asked the Plan to pre-approve Prolia. You say that the requested medication is necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
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 Prolia. Our reviewer says that the medication is not medically necessary. Our physician reviewer found per the submitted documentation, the enrollee is on Boniva. There is no specific clinical rationale for the requested medication, Prolia. The review has determined that the documentation does not support that the Prolia is medically reasonable or necessary for the enrollee. The documentation does not support that the Prolia is safe and effective 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 Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia (J0897).
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 services are necessary. The Plan denied your
request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described above.
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 the documentation does not support that the enrollee is stable for transfer to an IRF
level of care 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 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve oncology services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the OON services. You say that you need alternate treatment options. The Plan denied your request. The Plan says there is appropriate care available within 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 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 the requested services. Therefore, we decided that the Plan does not have to pre-approve oncology 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 pre-approve radiofrequency ablation (RFA) of the sacroiliac (SI)
nerves.
You asked the Plan to pre-approve the SI RFA procedure. You say that the enrollee would benefit from this
treatment. The Plan denied your request. The Plan says there is insufficient evidence to support the use of this
treatment.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We 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 SI RFA procedure. Our reviewer
says that the requested services are not considered medically reasonable and necessary in this case. Our
physician reviewer found The enrollee has postlaminectomy syndrome, with Spondylosis without myelopathy
or radiculopathy, lumbar region. The enrollee reported very good relief with RFA in April, 2020, "typically 70
to 80%". Radiofrequency ablation has not been consistently shown to provide additional lasting benefit for the
treatment of low back pain, when added to a treatment regimen of conservative measures.
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 SI RFA procedure have not been met. Therefore, we decided that the Plan
does not have to pre-approve radiofrequency ablation (RFA) of the sacroiliac (SI) nerves.
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 you would like the plan to reconsider their denial.
The Plan denied your request. The Plan says the requested admission is not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described above.
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 the enrollee required maximum assistance with bed mobility, transfers, and lower
body dressing. The enrollee required moderate assistance with upper body dressing. The documentation does
not support evidence of complex medical issues that require monitoring by an inpatient physical medicine and
rehabilitation physician three times per week or need for acute rehab nursing care. The documentation supports
that the enrollee may benefit from further physical therapy and occupational therapy, but the enrollee does not
require an intensive therapy program.
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 pre-approve a U-walker for the enrollee.
You asked the Plan to pre-approve the walker. You say that this is medically necessary. The Plan denied your
request. The Plan says the request was made using a miscellaneous walker code, which is incorrect.
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 the walker. Our reviewer says that the
requested walker is not considered medically reasonable and necessary in this case. Our physician reviewer
found the documentation does not reveal that the enrollee needs this brand device for the diagnosis or treatment
of illness or injury or to improve the functioning of a malformed body member. The documentation does not
reveal evidence that the walker is being prescribed in accordance with accepted standards of medical practice
or the diagnosis or treatment of this enrollee's condition, or to improve the function of a malformed body
member or why this brand of walker is more beneficial for this enrollee's condition than a standard walker.
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 walker have not been met. Therefore, we decided that the Plan does not
have to pre-approve a U-walker for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia (J0897) and Leuprolide Acetate Depot (J9217).
You asked the Plan to pre-approve the Prolia and Leuprolide Acetate Depot. You say that you would like
reconsideration because the incorrect diagnosis code was submitted with the appeal request. The Plan denied
your request. The Plan says sources do not support using this drug to treat bone loss associated with androgen
deprivation therapy for the treatment of prostate cancer without a diagnosis of osteopenia.
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 the Prolia and Leuprolide Acetate
Depot. Our reviewer says that Prolia is not FDA approved for metastatic prostate cancer. Our physician
reviewer found the requested use is not supported in any of the CMS approved compendia.
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 Prolia and Leuprolide Acetate Depot have not been met. Therefore, we
decided that the Plan does not have to pre-approve Prolia (J0897) and Leuprolide Acetate Depot (J9217).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for medical nutritional therapy provided to the enrollee on
January 29, 2020.
You asked the Plan to pay for medical nutrition therapy services. You say that this claim should be paid. The
Plan denied your request. The Plan says Medicare coverage criteria were not met.
The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services
only for enrollees with renal disease or diabetes. The records do not show that the enrollee suffers from renal
disease or diabetes. Therefore, we decided that the Plan does not have to pay for medical nutritional therapy
provided to the enrollee on January 29, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aloxi for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary for nausea and vomiting.
The Plan denied your request. The Plan says the standards have not been met for off-label use.
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 the drug. Our reviewer says that the
requested drug is not medically reasonable or necessary. Our physician reviewer found the enrollee is noted to
have multifactorial nausea and vomiting, for which Aloxi has been requested. The use of chemotherapy or
being in an immediately post-operative state are not noted. As such, the enrollee does not have a MAI for the
use of the requested drug.
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 drug have not been met. Therefore, we decided that the Plan does not have
to pre-approve Aloxi for the enrollee.
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 you would like the plan to reconsider their denial.
The Plan denied your request. The Plan says the requested admission is not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described above.
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 you required maximum assistance with upper body dressing. You were dependent for
lower body dressing. You required minimal assistance with bed mobility. You required a two person lift for
transfers. The documentation does not support evidence of need for supervision by physical medicine and
rehabilitation Physician or needs acute rehab nursing care. While you may benefit from further physical
therapy and occupational therapy, you do not require an intensive therapy program. Your care needs can be met
at a lower level of care.
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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Oxycontin.
You asked the Plan to pre-approve Oxycontin. You say that the enrollee has been stable on this medication.
The Plan denied your request. The Plan says this medication does not fall under Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered
drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Oxycontin.
Benefits for Oxycontin 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: 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 services are necessary. The Plan denied your
request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described above.
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 the enrollee is generally medically stable and the documentation does not support that
she has complex medical issues that require acute rehab nursing care, or monitoring by an inpatient physical,
medicine, and rehabilitation (PMR) physician three times per week. While the enrollee is reasonably expected
to benefit from continuing physical therapy (PT) and occupational therapy (OT), the documentation does not
support that there is need for an intensive therapy program with therapy 3 hours per day, with frequent
physician oversight and an interdisciplinary approach to rehabilitation care.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan has to pre-approve nasal valve repair and uvulectomy for the enrollee.
You asked the Plan to pre-approve the procedures. You say that this is medically necessary. The Plan denied
your request. The Plan says that there is insufficient published evidence to assess the impact on a patient's
health outcomes.
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 procedures. Our reviewer says that
the requested services are considered medically reasonable and necessary in this case. Our physician reviewer
found CPT code 42145, has been approved - the palatopharyngoplasty. This procedure is medically reasonable
and necessary based on the enrollee's records and physical exam. A uvulectomy is part of the pharyngoplasty,
and is therefore also medically reasonable and necessary. The repair of the nasal valve is also medically
reasonable and necessary. The enrollee suffers from nasal obstruction and has nasal valve collapse on physical
exam. His nasal valve collapse responds to the cottle maneuver. This helps define the nasal valve collapse as
internal nasal valve collapse. This particular type of collapse can be improved with nasal valve repair. The
nasal valve repair is not necessarily for the diagnosis of OSA. It would be for the issues of nasal obstruction
and difficulty breathing through the nose. Therefore, an updated sleep study is not indicated prior to proceeding
with nasal valve repair.
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 procedures have been met. Therefore, we decided that the Plan has to preapprove
nasal valve repair and uvulectomy 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve complete upper and lower dentures.
You asked the Plan to pre-approve complete dentures. The Plan denied your request. The Plan says the
requested dentures are not the proper course of treatment.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers complete
dentures when the services are medically necessary and reasonable.
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 complete dentures. Our physician
reviewer found that a review of your dental record and radiographs indicate the presence of implant placements
in the mandibular and maxillary arches. Complete upper and lower dentures are not dentally reasonable and
necessary in this case, as you have implant placements.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
the Plan's rules for coverage of complete dentures have not been met. Therefore, we decided that the Plan does
not have to pre-approve complete upper and lower dentures.