Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve stereotactic body radiation therapy (SBRT).
You asked the Plan to pre-approve SBRT. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because there is no research showing that the enrollee's type of cancer responds better to shit treatment than the type of treatment the Plan will approve.
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 SBRT. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found for metastatic disease, SBRT is generally only indicated for patients with oligometastatic disease of for those undergoing palliation after prior radiation to the same site. Oligometastases are defined as a state of metastatic disease with metastases few in number and extent. The most recent American Society of Radiation Oncology (ASTRO) model SBRT coverage policy, reflecting national expert opinion, states that SBRT for metastatic lung, liver, adrenal, and kidney lesions is medically necessary when the patient's performance status justifies aggressive treatment, and for those whose tumor burden can be completely targeted with acceptable risks. National Comprehensive Cancer Network (NCCN) guidelines support SBRT only for patients with oligometastatic disease. This enrollee has widespread metastatic disease. The clinical records do not describe which of the many bone metastases would be treated (other than describing the need to palliate "rib pain" and "pelvic pain" is the setting of widespread metastases with new and progressive disease) or why SBRT would be needed or justifiable for this patient. Palliative dose fractionation using 2D or 3D conformal radiation can also achieve palliation (with dose escalation if recommended). While SBRT would not necessarily be inappropriate, the use of SBRT or intensity-modulated radiation therapy (IMRT) for an enrollee with bone metastases in the setting of widespread metastases would not be a standard of care. SBRT would arguably exceed the needs for this enrollee. The standard of care would be palliative radiotherapy with 2-dimensional or 3-dimensional conformal radiotherapy.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SBRT have not been met. Therefore, we decided that the Plan does not have to pre-approve stereotactic body radiation therapy (SBRT).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied
your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found the complexity of the member's nursing, medical and rehabilitation needs do not
require an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The
member does not require treatment by multiple therapies, including either physical therapy or occupational
therapy, at an intensive rehabilitation therapy program. The member continues to have a need for skilled
therapy with ongoing safety concerns and a potential for functional improvement however, the documentation
does not support that they would meet criteria for admission to an acute inpatient rehabilitation facility. There
is no indication that the member would require skilled rehabilitation in an IRF, participating in rehab services
fifteen (15) hours a week, under the supervision of a physician with at least three (3) visits weekly to regain or
maintain her functional status. The member is ambulating household distances with contact guard assistance.
The member is near their prior level of function and can receive services 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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis provided on October 3, 2020
You asked the Plan to pay for the lumbar-sacral orthosis (L0650). You say that the orthosis was medically necessary. The Plan denied your request. The Plan says the enrollee did not receive a video or telephonic visit by the ordering physician in order to warrant the codes billed.
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 lumbar-sacral orthosis (L0650). Our reviewer says that the orthosis is not medically necessary. Our physician reviewer found the available documentation in the case file does not support that the requested lumbar-sacral orthosis (LSO)was medically reasonable and necessary for the enrollee in this case, according to the coverage criteria established by the LCD. An appropriate history and a physical examination of the back would reasonably be required to adequately assess whether the coverage criteria for an LSO have been met. The documentation does not support that the lumbar-sacral orthosis was prescribed for one or more of the covered indications in this case, as there is insufficient documentation of an appropriate evaluation of the enrollee and insufficient documentation of a credible physical examination of the back. 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 lumbar-sacral orthosis (L0650) have not been met. Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis provided on October 3, 2020
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for psychotherapy services provided by a participating provider on October 7, 2019.
You asked the Plan to waive the copayment for psychotherapy services. You say that this was a mistake. You say that you did not know that this was considered psychotherapy. You say that you would not have had these services if you had known. The Plan denied your request. The Plan says the correct copayment has been 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 $20 copayment for outpatient mental health care/in-network/individual. You have been asked to pay a $20 copayment for psychotherapy services. The correct copayment has been applied to the services that were provided. Psychotherapy services falls within the outpatient mental health care/in-network/individual 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 psychotherapy services provided by a participating provider on October 7, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient mental health care from 4/25/2021, forward.
You asked the Plan to pre-approve the continuation of inpatient mental health care. You say that this is medically necessary. The Plan denied your request. The Plan says medical necessity criteria was not met for inpatient mental health services.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the continuation of inpatient mental health care. Our reviewer says that the requested inpatient mental health care is not medically reasonable and necessary. Our physician reviewer found this 32-year-old female was admitted to the acute inpatient psychiatric hospitalization on April 25, 2021 with Major Depressive Disorder. Based upon a review of the records provided it was not expected this enrollee would improve beginning April 26, 2021, in a reasonable period of time as she did not have dangerousness to self or others and was not showing any auditory/visual hallucinations or any aggressive behaviors. It did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care as she did not have dangerousness to self or others. It did not appear that active treatment was taking place. It did not appear that the services were reasonably expected to improve the patient's condition or for the purpose of diagnosis. Based upon review the records provided for the admission of this patient does not meet criteria for acute inpatient mental health treatment as this patient was not shown to be a danger to herself or others, no auditory or visual hallucinations beginning April 26, 2021. 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 continuation of inpatient mental health care have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient mental health care from 4/25/2021, forward.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a standard manual wheelchair (K0001) for the enrollee.
You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied your request. The Plan says the medical records state that the enrollee is able to get around.
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 wheelchair. Our reviewer says that
the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found it is not clear that the enrollee's mobility limitation significantly impairs the ability to complete MRADLs, or cannot be resolved by a cane or walker. The documentation is not clear whether the enrollee's home is appropriate for a wheelchair, or that the wheelchair will significantly improve the enrollee's ability to complete MRADLs. 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 wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve a standard manual wheelchair (K0001) for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the mobile x-ray services rendered on November 3, 2020.
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 the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that codes with a PC/TC indicator of 1 have both a PC and TC. Codes with a PC/TC indicator of 3 have a TC only. We looked at the file and Medicare rules. Billed procedure code 71045 has a PC/TC indicator of 1. The PC and TC were not performed in a separate payment locality and are not separately payable. Billed procedure codes R0070 and Q0092 have a PC/TC indicator of 3 and no separate PC payment. Therefore, we decided that the Plan does not have to pay for the mobile x-ray services rendered on November 3, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care
after May 1, 2021.
You asked the Plan to pre-approve the continuation of SNF care. You say that you continue to need SNF care.
The Plan denied your request. The Plan says rules for continued SNF care have not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the continuation of SNF care. Our
reviewer says that daily skilled services are not necessary. Our physician reviewer found you are a 76-year-old
female with a past medical history of rheumatoid arthritis, pubic fracture and muscle weakness who was
admitted to a skilled nursing facility on March 25, 2021. Based on the medical records provided, while you
continue to require skilled therapy services there is no documentation that you continue to require skilled
nursing services to safely and effectively provide medically necessary and reasonable treatment. Furthermore,
you do not require the requested services on an inpatient basis that can only be provided in a SNF. Services in a
long-term care facility on a part time basis or in the home with home health services appear appropriate in this
case.
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 continuation of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care after May 1, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the parathyroid imaging provided on November 13, 2020.
You asked the Plan to waive the copayment for the parathyroid imaging. You say that you contacted the Plan prior to scheduling this procedure and were advised it would be covered. The Plan denied your request. The Plan says the copayment applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 copayment for nuclear medicine services at an outpatient hospital. You have been asked to pay a $250 copayment for the parathyroid imaging. The parathyroid imaging falls within the "Outpatient diagnostic tests and therapeutic services and supplies" 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 the parathyroid imaging provided on November 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a left knee brace (L1833) and a suspension sleeve (L2397) provided on August 24, 2020.
You asked the Plan to pay for a knee brace and a suspension sleeve. You say that the requested items are a necessity for the enrollee's care. The Plan denied your request. The Plan says rules for payment have not been met.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record does not contain a valid proof of delivery for the supplies provided in this case. Specifically, the document submitted as proof of delivery does not indicate the specific supplies delivered. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for a left knee brace (L1833) and a suspension sleeve (L2397) provided on August 24, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for coronary artery bypass grafting and aortic valve replacement. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 testing provided on October 1, 2020.
You asked the Plan to pay for the testing services. You say that the testing was ordered to determine if there was a more effective therapy to treat the enrollee's advanced cancer. The Plan denied your request. The Plan says coverage criteria have not been met.
The Plan must follow Medicare rules. Medicare rules say that Guardant360 testing is only covered under certain medical indications.
We looked at the file and Medicare rules. The records provided in the case file do not indicate that a tissue-based comprehensive genomic profile was infeasible. Based on this information, we decided that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that the Plan does not have to pay for the Guardant360 testing provided on October 1, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 3 power wheelchair with multiple power options (K0861).
You asked the Plan to pre-approve the group 3 power wheelchair with multiple power options. You say that the group 3 power wheelchair with multiple power features is medically necessary. The Plan denied your request. The Plan says coverage criteria is not met.
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. 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 group 3 power wheelchair with multiple power options. Our reviewer says that the group 3 power wheelchair with power options is not medically necessary. Our physician reviewer found the documentation states that the member can get on and off the wheelchair. This is inconsistent with the inability to perform weight shifts. Furthermore, the member does not have skin breakdown or decubiti. Only a single power or function, power elevating leg rests is supported by the documentation available. 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 group 3 power wheelchair with multiple power options have not been met. Therefore, we decided that the Plan does not have to pre-approve a group 3 power wheelchair with multiple power options (K0861).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Nivolumab.
You asked the Plan to pre-approve Nivolumab. You say that you would like the plan to reconsider their denial.
The Plan denied your request. The Plan says the requested drug is not medically necessary.
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 Nivolumab. Our reviewer says that the
documentation does not support that the requested drug is medically reasonable or necessary. Our physician
reviewer found the enrollee has esophageal cancer. The documentation does not support that the requested drug
is FDA-approved for the enrollee's diagnosis. Nivolumab is not supported by one of the major drug compendia
or by clinical research that appears in a CMS-approved medical journal as a single agent. Therefore, the
enrollee does not meet criteria for 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 Nivolumab have not been met. Therefore, we decided that the Plan does not
have to pre-approve Nivolumab.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services (A0426 and A0425) provided on December 29, 2020.
You asked the Plan to pay for the ambulance services. You say that you would like reconsideration because this claim was billed with appropriate diagnosis codes. The Plan denied your request. The Plan says this claim was not billed and an appropriate primary diagnosis code.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We find that CPT code A0426 and A0425 is not supported in the medical record. Specifically, this claim was billed with diagnosis code I25.82. This diagnosis code has a code first note, meaning, the underlying condition should be sequenced first. Based on this information, we decided that Medicare rules for coverage of the ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for the ambulance services (A0426 and A0425) provided on December 29, 2020.