Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that LTACH care is medically necessary. The Plan denied your request. The Plan says LTACH care is not medically necessary because the patient is receiving appropriate in-patient 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 there is no documentation provided necessitating admission to an LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only
on an inpatient basis. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvespinal fusion surgery.You asked the Plan to pre-approvespinal fusion surgery. You say that your physician is willing to perform this surgery knowing that you are a smoker and purchasing Chantix would be a financial burden.The Plandenied your request. The Plan says the denial of authorization for this service is correct, because you are a daily smoker and records have not confirmed smoking cessation for at least 6 weeks which is a contraindication to surgery.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 indenying the request to pre-approve spinal fusion surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found smoking is a contraindication to spinal fusion surgery as it results in high fusion failure rates. You must stop smoking for 3 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 spinal fusion surgery have not been met. Therefore, we decided that the Plan does not have to pre-approvespinal fusion surgery
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the subsequent observation care (99224) provided March 12, 2021, to March 15, 2021.
You asked the Plan to pay for the subsequent observation care. You say that these services were medically necessary, and the provider is able to accept payment from Medicare. The Plan denied your request. The Plan says that this provider is not eligible to receive payment from Medicare.
The Plan must follow Medicare rules. Medicare rules say that a provider must be eligible to participate in Medicare to receive payment. We looked at the file and Medicare rules. In this case, the Plan has denied payment based on the taxonomy billed. However, regardless of the taxonomy billed, we have confirmed that the provider is a certified Nurse Practitioner (NP) so there is no basis they cannot be paid based on her status. Based on this information, we decided that Medicare rules for coverage of the subsequent observation care have been met. Therefore, we decided that the Plan has to pay for the subsequent observation care (99224) provided March 12, 2021, to March 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvespecialist services to be provided by an out of network (OON) provider.You asked the Plan to pre-approvespecialist services. You say that you would like approval to see this out-of-network provider.The Plan denied your request. The Plan says there are in-network providers available for these services.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 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-approvespecialist services to be provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve the pathology examination of tissue using a microscope (88305) provided February 2, 2021.
You asked the Plan to pre-approve the pathology examination of tissue using a microscope. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says that these services are not covered under the medical plan because they should be considered dental in nature.
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 pathology examination of tissue using a microscope. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found that a review of the patient's medical record indicates that the biopsy was performed to determine the diagnosis of the lesion. Based on the documentation provided, this procedure should be considered medical in nature and no treatment of the teeth or the supporting structures of the teeth were involved. 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 pathology examination of tissue using a microscope have been met. Therefore, we decided that the Plan has to pre-approve the pathology examination of tissue using a microscope (88305) provided February 2, 2021.
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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approvePimecrolimus cream 1%.You asked the Plan to pre-approvePimecrolimus cream. You say that Pimecrolimuscream is medically necessary.The Plan denied your request. The Plan says Pimecrolimus cream is not eligible for coverage under the Part B medical benefit.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not payfor 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-approvePimecrolimus cream 1%. Benefits for Pimecrolimus creammay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea general use wheelchair seat cushion.You asked the Plan to pre-approvegeneral use wheelchair seat cushion. You say that you are appealing this denial.The Plan denied your request. The Plan says the denial of authorization for this item is correct, because the record does not show that enrollee has a wheelchair.The Plan must follow Medicare rules. Medicare rules say that if a beneficiary does not have a covered wheelchair, then a wheelchair cushion will be denied as not reasonable and necessary. We looked at the file and Medicare rules. The record does not show that the enrollee has a covered wheelchair for which this cushion may be needed. Based on this information, we decided that Medicare rules for coverage of general use wheelchair seat cushion have not been met.Therefore, we decided that the Plan does not have to pre-approvea general use wheelchair seat cushion.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda.

You asked the Plan to pre-approve the drug. You say that this is medically necessary.The Plan denied your request. The Plan says there are not enough studies in the medical literature showing that this medication will improve health outcomes for ovarian cancer.

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. 

The file shows that Keytruda is being requested for ovarian cancer. The Medicare-approved compendia and related guidelines state that Keytruda is considered still investigational for use in treatment of ovarian cancer. 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 Keytruda.
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 requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.
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 enrollee does not meet criteria for IRF admission. Our physician reviewer found based on the documentation provided, 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a surgical placement of implant body: endosteal implant (D6010), custom fabricated abutment (D6057), and abutment supported porcelain/ceramic crown (D6058).
You asked the Plan to pre-approve the endosteal implant, custom fabricated abutment, and abutment supported crown. You say that these services are necessary to restore optimal well-being of the enrollee's overall dental condition. The Plan denied your request. The Plan says these services are not covered under the enrollee's plan.
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. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a surgical placement of implant body: endosteal implant (D6010), custom fabricated abutment (D6057), and abutment supported porcelain/ceramic crown (D6058).
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Entyvio, 300mg intravenous solution.
You asked the Plan to pre-approve Entyvio. You say that the requested drug is medically necessary. The Plan denied your request. The Plan says that the enrollee has not tried and failed the preferred drugs, Inflectra or Renflexis. The Plan also says that you have not demonstrated why it is medically necessary to make an exception for the enrollee.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 Entyvio. Our reviewer says that Entyvio is medically necessary. Our physician reviewer found the provided medical records do not support that the enrollee has tried and failed the required drugs. The reviewer found that the medical records indicate that the plan's required drugs may have adverse effects for the enrollee based on their medical history. The reviewer also found that the requested drug, Entyvio does not cause an increased risk of malignancy. Therefore, the reviewer found that Entyvio is medically reasonable and 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 Entyvio have been met. Therefore, we decided that the Plan has to pre-approve Entyvio, 300mg intravenous solution.
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: 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 requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.
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 enrollee does not meet criteria for IRF admission. 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 pneumonia, a spinal abscess and bacteremia. Medical conditions 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, in an intensive rehabilitation therapy program. The enrollee does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Positron Emission Tomography (PET) scan and a Computed Tomography (CT) scan (78815)
You asked the Plan to pre-approve a PET/CT scan. You say that the requested PET/CT scan is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested PET/CT scan.
The Plan must follow Medicare rules. Medicare rules say that PET imaging for initial anti-cancer strategy is non-covered for enrollees with prostate cancer. Therefore, we decided that the Plan does not have to pre-approve a Positron Emission Tomography (PET) scan and a Computed Tomography (CT) scan (78815)
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 service is medically necessary. The Plan denied your request. The Plan says the service 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 patient does not require treatment by multiple therapies and there are no complex nursing or rehabilitation needs.
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. Specifically, medically necessary services can be obtained at a lower level of care. This means admission into an IRF is not medically necessary. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approveinsertion of an interspinous spacer device (Vertiflex).You asked the Plan to pre-approveVertiflex. You say that the enrollee has failed conservative approaches to treatment and is a good candidate for this procedure.The Plandenied your request. The Plan says the denial of authorization for this service is correct, because Vertiflex is experimental and not considered the standard of care.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 Vertiflex. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental. More research is needed to show safety and efficacy of this device. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Vertiflex have not been met. Therefore, we decided that the Plan does not have to pre-approveinsertion of an interspinous spacer device (Vertiflex).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on October 18, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis code.
Billed procedure code 87088 (culture, bacterial; with isolation and presumptive identification of each isolate,
urine) was not billed with an appropriate covered diagnosis code.
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically
appropriate NCCI modifier is used to report the reason it should be paid as well.
The provider submitted a claim for procedure codes 81003 (urinalysis by dip stick, automated, without
microscopy) and 81001 (urinalysis by dip stick, automated, with microscopy). Code 81003 is a column II code
with a modifier indicator of 1 when billed with column I code 81001. Code 81003 was not billed with an
appropriate modifier to allow for separate payment.
The provider submitted a claim for procedure codes 81000 (urinalysis by dip stick, non-automated, without
microscopy) and 81001 (urinalysis by dip stick, automated, with microscopy). Code 81000 is a column II code
with a modifier indicator of 1 when billed with column I code 81001. Code 81000 was not billed with an
appropriate modifier to allow for separate payment.
The provider submitted a claim for procedure codes 81015 (urinalysis, microscopic only) and 81001 (urinalysis
by dip stick, automated, with microscopy). Code 81015 is a column II code with a modifier indicator of 1 when
billed with column I code 81001. Code 81015 was not billed with an appropriate modifier to allow for separate
payment.
Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on October 18, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150), and an extraction (D7210).
You asked the Plan to pre-approve a comprehensive oral evaluation, and an extraction. You say that you are in pain and need these services done. The Plan denied your request. The Plan says the services at issue are not covered unless they are performed by a participating general dentist. Dental services performed by an oral surgeon are not covered.
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. We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a comprehensive oral evaluation, and an extraction have not been met. Specifically, the services at issue are not covered unless they are performed by a participating general dentist. Therefore, we decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150), and an extraction (D7210).