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

We decided that the Plandoes not haveto pre-approveinpatient psychiatric services for the enrollee.You asked the Planto pre-approvethe services. You say that this is medically necessary.The Plandenied your request. The Plansaysalthough the enrollee no longer meets the criteria for this level of care, there are other services that may be available as part of the mental health benefits.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 services. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found it is not expected that this enrollee would improvein a reasonable period of time for the dates in question as she did not have suicidal or homicidal ideation noted and no auditory or visual hallucinations. 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 beyond the dates in question as she did not have dangerousness to self or others but was compliant with her treatment. The health plan's denial of continued inpatient psychiatric services is appropriate.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-approveinpatient psychiatric services 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 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 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 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for MRI of spinal contents (72158) provided on November 6,
2019.
You asked the Plan to pay for the MRI. You say that you would like reconsideration based on the records
submitted. The Plan denied your request. The Plan says the documentation submitted does not support the
service billed.
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 72158 is magnetic resonance (eg, proton) imaging, spinal
canal and contents, without contrast material, followed by contrast material(s) and further sequences; lumbar.
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the
Plan was correct in denying the request to pay for the MRI. Our reviewer says that CPT code 72158 does not
meet criteria for billing or reimbursement consideration. Our reviewer found the medical records provided does
not include documentation of a Magnetic resonance (eg, proton) imaging, spinal canal and contents, without
contrast material, followed by contrast material(s) and further sequences; lumbar being performed on
November 6, 2019, therefore this service cannot be verified.
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the MRI have not been met. Therefore, we decided that the Plan does not have
to pay for MRI of spinal contents (72158) provided on November 6, 2019.
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 these services are medically necessary. The Plan denied your request. The Plan says that you can safely receive the services you need in other settings.
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. You do require treatment by multiple therapies, including both physical therapy and occupational therapy, but do not require an intensive rehabilitation therapy program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. The documentation from the hospital does not support that you can tolerate or have received three hours of rehab in a day. Our physician reviewer found that your condition does not meet Medicare criteria for IRF 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 does not have to pay for the office visits and waive the coinsurance for the chiropractic services provided by a chiropractor from May 1, 2019 to May 30, 2019.
You asked the Plan to pay for the office visits and waive the coinsurance for the chiropractic services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the claims have been processed correctly per your plan benefits.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The rules also 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 50% coinsurance for Medicare covered chiropractic services provided by an out of network provider.
You have been asked to pay for the office visit and 50% coinsurance of the chiropractic manipulative treatment. The records show that the office visit service at issue is not manual manipulation of the spine. The allowed amount for the chiropractic manipulative treatment services was $40.52. Therefore, you were asked to pay $20.26 for each of the chiropractic manipulative treatment services received May 1, 2019 to May 30, 2019.
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. The records show that the office visit service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the office visits and waive the coinsurance for the chiropractic services provided by a chiropractor from May 1, 2019 to May 30, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda for the enrollee.You asked the Plan to pre-approve Keytruda. You say that this is medically necessary for the enrollee.The Plan denied your request. The Plan says that this is not covered for the enrollee's diagnosis.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 Keytruda. Our reviewer says that Keytruda is not medically reasonable and necessary for the enrollee in this case. This drug is not FDA approved for first line treatment of esophageal cancer. This drug is not supported in any of the CMS approved compendia for the requested use. There are no supportive citations in a PubMed search. The use is not listed as not indicated, not supported or not recommended in any of the compendia. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for Keytruda.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Keytruda have not been met.Therefore, we decided that the Plan does not have to pre-approve Keytruda for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea low dose CT scan for lung cancer screening.You asked the Planto pre-approvethe scan. You say that this is medically necessary.The Plandenied your request. The PlansaysMedicare criteria are not met.The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 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 scan. Our reviewer says that the requested scan is not medically reasonable or necessary. Our physician reviewer found you do not qualify because: 1. You are symptomatic with shortness of breath, leukocytosis and anemia. 2. While you have a smoking history, you do not have the CMS requirement of at least 30 pack years. You do not qualify for the ordered low dose lung CT for lung cancer screening. 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 scan have not been met.Therefore, we decided that the Plandoes not haveto pre-approvea low dose CT scan for lung cancer screening.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued physical therapy with an out-of-network
provider.
You asked the Plan to pre-approve continued physical therapy with an out-of-network provider. You say that
the continued physical therapy with the out-of-network provider is medically necessary. The Plan denied your
request. The Plan says the continued physical therapy with the out-of-network provider is not medically
necessary.
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan
providers available to meet enrollees' needs. Your contract with the Plan says that, with few exceptions, you
must use contract providers for care.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve continued physical therapy with an outof-
network provider. Our reviewer says that the continued physical therapy with the out-of-network provider is
not medically necessary. Our physician reviewer found the enrollee underwent right reverse total shoulder
surgery on 7/7/20. The recommended therapy regimen was 2 sessions per week for 30 - 60 minutes per session,
for 19 weeks to optimize her level of function. Based on the documentation provided, the enrollee is not
currently receiving any active treatment and/or medical management of her condition that makes it medically
necessary for this enrollee to continue care with the out-of-network physical therapy provider. There is nothing
unique about the enrollee's condition that would make it medically necessary for her to continue care with the
out-of-network provider. The Plan has shown that they have in-network physical therapy specialists who have
the qualifications and expertise necessary to meet the current medical Standards of Care required for treatment
of the enrollee's condition. The enrollee's medical management and/or follow-up care can be safely transitioned
to an in-network physical therapy specialist 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 continued physical therapy with an out-of-network provider have not been met.
Therefore, we decided that the Plan does not have to pre-approve continued physical therapy with an out-ofnetwork
provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic manipulative treatment (98941), office visit (99203), mechanical traction therapy (97012), electric stimulation therapy (97014), and the manual therapy (97140) provided February 21, 2020 to March 11, 2020.You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment.The Plan denied your request. The Plan says your primary care physician (PCP) must provide you with a referral to an in-network provider for chiropractic services.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the enrollee's primary care physician must provide an approval in advance to utilize providers in the Plan's network, such as specialists, hospitals, skilled nursing facilities, or home health care agencies.Your primary care physician (PCP) did not provide a referral for the chiropractic services provided. Your primary care physician must provide you with an approval in advance to utilize an in-network provider for chiropractic services. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services.Therefore, we decided that the Plan does not have to pay for the chiropractic manipulative treatment (98941),office visit (99203),mechanical traction therapy (97012), electric stimulation therapy (97014), and the manual therapy (97140) provided February 21, 2020 to March 11, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda.
You asked the Plan to pre-approve Keytruda. 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 Keytruda. 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 metastatic colon cancer that is not MSI-high/MMR-deficient. The
documentation does not support that the requested drug is FDA-approved for the enrollee's diagnosis. The use
of the requested drug is not supported by one of the major drug compendia or by clinical research that appears
in a CMS-approved medical journal.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have
to pre-approve Keytruda.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided in an urgent care center identified with code S9088 provided on October 27, 2019.
You asked the Plan to pay for the services provided in an urgent care center. 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 payable.
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 S9088 is services provided in an urgent care center (list in addition to code for service). We find that CPT code S9088 is not supported in the medical record. Specifically, code S9088 has a status code of "I". A status code of I means that this code is not valid for Medicare purposes. Medicare uses another code for reporting of, and payment of these services. Based on this information, we decided that Medicare rules for coverage of the services provided in an urgent care center have not been met. Therefore, we decided that the Plan does not have to pay for the services provided in an urgent care center identified with code S9088 provided on October 27, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) and a complete mandibular denture (D5120).
You asked the Plan to pre-approve the complete maxillary and mandibular dentures. You say that the enrollee received a full set of dentures in 2018 that no longer fit. You also say that the enrollee has called the Plan requesting a new set of dentures due to the fact his current pair no longer fits or works for him. The Plan denied your request. The Plan says these services exceed the maximum count allowed per period.
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, complete maxillary denture (D5110) and complete mandibular denture (D5120) are each limited to one procedure every five plan years. The record shows that the enrollee received a complete maxillary denture (D5110) and a complete mandibular denture (D5120) on October 4, 2018 and the enrollee's complete maxillary denture (D5110) and complete mandibular denture (D5120) benefits have been exhausted. Therefore, we decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) and a complete mandibular denture (D5120).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the allergy injection provided on January 2,
2020.
You asked the Plan to waive the copayment for the allergy injection. You say that you have not been charged a
copayment for allergy shots prior to 2020. The Plan denied your request. The Plan says you have been charged
the correct cost sharing amount.
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 per visit to a specialist. For this date of service, you have been asked to pay the allowed amount of
the claim because this amount is less than the $20 copayment for the allergy injection.
You have been asked to pay an $8.98 copayment for the allergy injection. The allergy injection falls within the
"Physician/Practitioner services, including doctor's office visits" benefit category. The record shows the
allergy injection is a physician service.
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 allergy injection provided on January 2, 2020.
Our decision is only about the January 2, 2020 services. If you have any questions about prior years billing,
please contact the plan directly.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forCPT code 38510 provided on December 12, 2019.You asked the Plan to pay forCPT code 38510. You say that the medical records support the billing of CPT code 38510.The Plan denied your request. The Plan says the medical records do not support the billing ofCPT code 38510.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 38510 is Biopsy or excision of lymph node(s); open, deep cervical node(s).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 CPT code 38510. Our reviewer says that the medical records do not support the billing of CPT code 38510. Our physician reviewer found the Provider billed Common Procedure Terminology 38510-Biopsy or excision of lymph node(s); open, deep cervical node(s). The health plandenied payment stating Common Procedure Terminology 38510-Biopsy or excision of lymph node(s); open, deep cervical nodes(s) is included with Common Procedure Terminology 35301 -RT. Common Procedure Terminology 38510 -Biopsy or excision of lymph node(s); open, deep cervical node(s) does not meet criteria. This code is inclusive to the main procedure.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CPT code 38510 have not been met.Therefore, we decided that the Plan does not have to pay forCPT code 38510 provided on December 12, 2019