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

We decided that the Plan does not have to pre-approve Cyclophosphamide, Carfilzomib, Ondansetron, Dexamethasone Sodium Phosphate for the enrollee.
You asked the Plan to pre-approve the drug regimen. You say that this is medically necessary. The Plan denied your request. The Plan says this drug/regimen is not being prescribed for a medically accepted indication.
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 regimen. Our reviewer says that the requested drug regimen is not medically reasonable or necessary. Our physician reviewer found the enrollee was treated with the same regimen in the past from 4/30/2020 until 1/13/2021. The requirement of having disease relapse after 6 months following primary induction therapy (which she had) was not met as not enough time has passed since the induction treatment. Therefore, this request for the above medication regimen will be considered not medically 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 the drug regimen have not been met. Therefore, we decided that the Plan does not have to pre-approve Cyclophosphamide, Carfilzomib, Ondansetron, Dexamethasone Sodium Phosphate for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on July 9, 2020, by an OON provider.You asked the Plan to pay fornursing facility care. You say that these medically necessary services were provided to the enrollee in good faith.The Plan denied your request. The Plan says rules for payment have not been met.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 had network providers available who could have provided 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 9, 2020, by an OON provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approveIntensity Modulated Radiation Therapy (IMRT) and image guided radiation therapy (IGRT).You asked the Plan to pre-approveIMRT and IGRT. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested services are not medically necessary.The Plan follows Medicare rules. Medicare rules say that IMRT and IRGT are only covered for certain indications.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 IMRT and IGRT. Our reviewer says that the documentation does not support that the requested services are medically reasonable or necessary. Our physician reviewer found the enrollee has portal hypertension, cirrhosis, splenomegally and thrombocytopenia. The LCD criteria are not met for the requested services.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IMRT and IGRT have not been met.Therefore, we decided that the Plan does not have to pre-approveIntensity Modulated Radiation Therapy (IMRT) and image guided radiation therapy (IGRT).
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 IRF care is medically necessary. The Plan denied
your request. The Plan says rules for IRF care have 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 does not require the intensity of services provided at an IRF.
Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular
physician evaluation. The enrollee's 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (G0483) provided on January 13, 2020.

You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says there were 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 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 had network providers available who could have provided 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 services. Therefore, we decided that the Plan does not have to pay for lab services (G0483) provided on January 13, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forthe adjacent tissue transfer or rearrangement coded 14301, muscle, myocutaneous, or fasciocutaneous flap coded 15733, and the surgical preparation or creation of recipient site by excision of open wounds coded 15004.You asked the Plan to pay forthe adjacent tissue transfer or rearrangement, muscle, myocutaneous, or fasciocutaneous flap, and the surgical preparation or creation of recipient site by excision of open wounds. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services billed are not supported by the documentation.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.We find that CPT codes 14301, 15733, and 15004 are not supported in the medical record. Specifically, operative report did not include documentation to meet the guidelines of an adjacent tissue transfer or rearrangement;any area; defect 30.1 sq cm to 60.0 sq cm; therefore, code 14301 cannot be verified.The operative report did not include documentation of muscle, myocutaneous, or fasciocutaneous flap; head and neck with named vascular pedicle (i.e., buccinators, genioglossus, temporalis, masseter, sternocleidomastoid, levator scapulae); therefore, code 15733 cannot be verified.The operative report did not include documentation of surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar contracture, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet and/or multiple digits; first 100 sq cm or 1% of body area of infants and children; as a separate procedure; therefore, code 15004 cannot be verified.
Based on this information, we decided that Medicare rules for coverage of the adjacent tissue transfer or rearrangement, muscle, myocutaneous, or fasciocutaneous flap, and the surgical preparation or creation of recipient site by excision of open wounds have not been met. Therefore, we decided that the Plan does not have to pay forthe adjacent tissue transfer or rearrangement coded 14301, muscle, myocutaneous, or fasciocutaneous flap coded 15733, and the surgical preparation or creation of recipient site by excision of open wounds coded 15004
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the shingles vaccine and administration (90750 and 90471)
provided on November 26, 2019.
You asked the Plan to pay for the shingles vaccine. You say that you would like reconsideration because the
member was covered at the time of service. The Plan denied your request. The Plan says the Zoster
immunization is not a covered as a preventative service after the age of 18 years.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the shingles vaccine.
The Plan follows the same rules.
Records do not show that you have been injured or directly exposed to any illness related to the shingles
vaccine. Therefore, we decided that the Plan does not have to pay for the shingles vaccine and administration
(90750 and 90471) provided on November 26, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Cinacalcet 90MG.
You asked the Plan to pre-approve Cinacalcet. 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 a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Cinacalcet 90MG.
Benefits for Cinacalcet 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-approvelong-term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that LTACH Admission is medically necessary.The Plan denied your request. The Plan says the enrollee can receive same services at the current level of care.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 the documentation doesnot 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.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-approvelong-term acute care hospital (LTACH) services
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveproton beam radiation therapy for the enrollee.You asked the Planto pre-approvethe therapy. You say that this is medically necessary.The Plandenied your request. The Plansaysthere is no indication that IMRT, IGRT, 4D-CT, or PET simulation radiation has been tried and failed.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 therapy. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the need for proton therapy for advanced lungcancer needs to be established an on individual basis with a plausible rationale as to why proton therapy is needed in lieu of more standard 3D conformal radiation or IMRT. A rationale for the need for proton therapy is not plausible and well-justified inthe case file.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 not been met.Therefore, we decided that the Plandoes not haveto pre-approveproton beam radiation therapy for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe Intracept spinal surgery (22899, C9752).You asked the Plan to pre-approvethe Intracept spinal surgery. You say that this procedure is the most viable option.The Plan denied your request. The Plan says this surgery is investigational and experimental.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 Intracept spinal surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found in this case, you have chronic low back pain and status post L4-5 fusion. You also received multilevel radiofrequency ablation in February 2020 with 75% relief that was only beginning to get worse lately (as noted on the September 2020 evaluation.) It appears that you have responded favorably to conservative care. In addition, the request is for the procedure at L2-3. This level is not supported by evidence-based literature. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception to the guidelines.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 Intracept spinal surgery have not been met.Therefore, we decided that the Plan does not have to pre-approvethe Intraceptspinal surgery (22899, C9752).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve intensity modulated radiation therapy (IMRT).
You asked the Plan to pre-approve IMRT. You say that this is medically necessary. The Plan denied your request. The Plan says this is not supported for the enrollee's condition.
The Plan follows Medicare rules. Medicare rules say that there must be documented rationale of the advantage of IMRT versus the use of other radiation therapy methods in the medical record of each patient for whom IMRT is provided. 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 IMRT. Our reviewer says that the criteria for coverage of the requested IMRT have not been met. Our physician reviewer found there is no documentation for why IMRT is needed for the rib metastases. The physician medical necessity certification is written in generic/template form without specifying quantitatively why IMRT is needed. Several normal tissues/organs are listed as being spared with IMRT without specifying how IMRT improves normal tissue sparing. There are screen captures of a 3D, wedge pair and IMRT plan without any explanation of why the non-IMRT plans would be unacceptable. There are no quantifiable dosimetric measures metrics used to justify the need for IMRT in this patient. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IMRT have not been met. Therefore, we decided that the Plan does not have to pre-approve intensity modulated radiation therapy (IMRT).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided on July 12, 2020 by an out of network provider.
You asked the Plan to pay for the physician services. You say that your doctor should not be penalized because the facility staff did not obtain the proper authorization. The Plan denied your request. The Plan says you did not request prior authorization.
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 had network providers available who could have provided 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 services. Therefore, we decided that the Plan does not have to pay for the physician services provided on July 12, 2020 by an out of network provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient mental health services provided by a participating provider fromJune 24, 2020, to June 30, 2020.You asked the Plan to waive the copayment for outpatient mental health services. You say that you do not agree with this copayment. 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 $40 copayment for outpatient mental health care/in-network. You have been asked to pay $35 which is less than your copayment amount of a $40 for outpatient mental health services. The total amount you are being asked to pay is $70 ($35 x 2 visits = $70). Outpatient mental health services fall within the outpatient mental health care/in-network 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 inthe Plan. Therefore, we decided that the Plan does not have to waive the copayment for outpatient mental health services provided by a participating provider fromJune 24, 2020, to June 30, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that you do not want to go to another facility.The Plan denied your request. The Plan says the denial of authorization for IRF service is correct, because you do not meet IRF criteria and can be treated in a less intensive setting such as skilled nursing facility.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 complexity of your nursing, medical, and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation. While the record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in, and benefit from, the intensive rehabilitation therapy program 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 topre-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that you cannot go home without this rehabilitation.The Plan denied your request. The Plan says the denial of authorization for IRF service is correct, because you do not meet IRF criteria and a lower level of care such as home health might be appropriate.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 complexity of your nursing, medical, and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the record shows a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in, and benefit from, the intensive rehabilitation 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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvegenicular nerve radiofrequency ablation.You asked the Planto pre-approvethe services. You say that  The Plandenied your request. The Plansaysthis is considered experimental and investigational.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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this procedure is considered experimental/investigational and it is the subject of on-going clinical trials. Therefore, the request is considered not medically reasonable or 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 services have not been met.Therefore, we decided that the Plandoes not haveto pre-approvegenicular nerve radiofrequency ablation.