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

We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that an acute inpatient rehabilitation facility admission is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of an inpatient rehabilitation facility 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 requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that the enrollee does not require the intensity of services provided at an acute inpatient rehabilitation facility. Specifically, the enrollee is not shown to require, or to be able to currently perform, fifteen hours per week of rehabilitative services with 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 an acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for neuromuscular junction testing (95937) provided on October
2, 2019.
You asked the Plan to pay for neuromuscular junction testing. You say that this code is supported. The Plan
denied your request. The Plan says this code was used for train of four testing.
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 95937 is neuromuscular junction testing (repetitive
stimulation, paired stimuli), each nerve, any 1 method.
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 neuromuscular junction testing. Our
reviewer says that this code is not supported. Our physician reviewer found CPT 95937 was used to report train
of four testing. According to CPT coding rules, train of four testing is not a separately reportable procedure and
is included in the other intraoperative neuromonitoring procedures.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of neuromuscular junction testing have not been met. Therefore, we decided that
the Plan does not have to pay for neuromuscular junction testing (95937) provided on October 2, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a total of 10 physical therapy (PT) sessions (six sessions are approved). You asked the Plan to pre-approve the four additional PT sessions. You say that the full amount of requested sessions should be approved. The Plan denied your request. The Plan says beyond the approved six sessions, it is not medically reasonable and necessary for physical therapy to continue. The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 four additional PT sessions. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the patient has had extensive therapy for her condition and the documentation does not reveal that she requires ongoing supervised therapy for her deficits. She is at a functional level that does not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or under the supervision of a therapist. The patient should be able to transition to an independent home exercise program. The requested services are not part of a maintenance program, and the specialized skill, knowledge and judgment of a qualified therapist are not required to establish, design and/or deliver a program to maintain the patient's current condition or to prevent or slow further deterioration. 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 four additional PT sessions have not been met. Therefore, we decided that the Plan does not have to pre-approve a total of 10 physical therapy (PT) sessions (six sessions are approved).
Appeal type: Lab
Decision: Partially Favorable

You asked the Plan to pre-approve genetic tests. You say that these tests are medically necessary in order to better understand the biology driving the enrollee's tumor growth. The Plan says that the denial of authorization for these services is correct, because the use of this testing has not been shown to improve outcomes for the enrollee's condition.
We decided that the Plan has to pre-approve MLH1, MSH2, MSH6, PMS2, and ERBB2 tests.
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 genetic tests. Our reviewer says that the requested MLH1, MSH2, MSH6, PMS2, and ERBB2 tests are considered medically reasonable and necessary in this case. Our physician reviewer found MLH1, MSH2, MSH6, and PMS2 are for MSI testing which can be used to approve Keytruda. ERBB2 test, if overexpressed, can be used to approve Folfox and Herceptin. Therefore, these tests are medically necessary. Therefore, we decided that the Plan has to pre-approve MLH1, MSH2, MSH6, PMS2, and ERBB2 tests.
We also decided that the Plan does not have to pre-approve the remaining requested genetic tests.
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 genetic tests. Our reviewer says that the remaining requested genetic tests are not medically necessary and do not meet the Medicare criteria for coverage. Therefore, we decided that the Plan does not have to pre-approve the remaining requested genetic tests.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a septoplasty.
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan
denied your request. The Plan says the services are not medically necessary.
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 these services. Our reviewer says that
the services are not medically necessary. Our physician reviewer found the submitted records show that you
have moderate nose swelling. The physical exam showed a deviated septum with inflammation and swelling of
the nose (rhinitis). Although you have a deviated septum, the documented symptoms are not consistent with
nasal obstruction or difficulty breathing through the nose. There are no reported issues with nasal breathing.
The septoplasty is not reasonable or medically necessary based on the submitted records.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve a septoplasty.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an inpatient skilled nursing facility (SNF) admission.
You asked the Plan to pre-approve SNF care. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of an inpatient skilled nursing facility admission.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 SNF care. Our reviewer says that the enrollee does not meet criteria for coverage of an inpatient skilled nursing facility admission. Our physician reviewer found that the enrollee does not require ongoing skilled nursing services to safely and effectively provide medically necessary and reasonable treatment. The enrollee does not have complex wound care, a need for IV antibiotics, enteral feedings or other skilled nursing needs. The enrollee's functional level does not require skilled therapy services to safely and effectively provide medically necessary and reasonable treatment only in a SNF. It is not medically reasonable and necessary to provide skilled nursing or skilled therapy services (or a combination of these services) on a daily basis in a skilled nursing facility. As a practical matter this enrollee does not require the necessary services on an inpatient basis, in a skilled nursing facility setting.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve an inpatient skilled nursing facility (SNF) admission.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly services coded 99190 provided on December 30, 2019.
You asked the Plan to pay for the assembly services. 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 separately 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 99190 is assembly and operation of pump with oxygenator or heat exchanger (with or without ECG and/or pressure monitoring); each hour. We find that CPT code 99190 is not supported in the medical record. Specifically, the enrollee was inpatient during these services. Therefore, payment for this service is included in the facility payment. Based on this information, we decided that Medicare rules for coverage of the assembly services have not been met. Therefore, we decided that the Plan does not have to pay for the assembly services coded 99190 provided on December 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cryoablation surgery.
You asked the Plan to pre-approve the requested services. You say that the enrollee has a clinically significant prostate cancer which requires treatment. The Plan denied your request. The Plan says there is no record of a failed trial of radiation therapy.
The Plan follows Medicare rules. Medicare rules say that cryosurgery of the prostate is only covered under certain medical 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 the requested services. Our physician reviewer found that the enrollee has T1c prostate cancer with a Gleason score of 7, and a PSA of <8ng/mL. However, the enrollee has not failed a trial of radiation therapy as their primary treatment. Therefore, the requested services are not medically 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 requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve cryoablation surgery.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve artificial disc replacement.
You asked the Plan to pre-approve artificial disc replacement. 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 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 artificial disc replacement. Our
reviewer says that the requested items/services are not considered medically reasonable and necessary in this
case. Our physician reviewer found the enrollee has lumbar spinal stenosis. The records show that the plan is to
perform surgery with the superion spinous process spacer. That device is experimental and not needed in this
case. More research is needed to show safety and efficacy of the 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 artificial disc replacement have not been met. Therefore, we decided that the
Plan does not have to pre-approve artificial disc replacement.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia (Denosumab).
You asked the Plan to pre-approve the Prolia (Denosumab).. You say that the enrollee has already been on bisphosphates for 5 years and I would not use Reclast. The Plan denied your request. The Plan says the documentation shows that the enrollee has tried Risedronate, but has not tried Zoledronic Acid. The Plan also says that the Plan's criteria have not been met and 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 the Prolia (Denosumab).. Our reviewer says that Prolia (Denosumab) is not medically necessary. Our physician reviewer found the provided medical records do not indicate that the patient has tried and failed the required drug, Prolia. Our reviewer also found that the provided medical records do not indicate that the Plan's required drug would likely be less effective and/or likely have adverse effects for the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Prolia (Denosumab). have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia (Denosumab).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-ofnetwork
provider on December 19, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not
authorized.
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 has network providers
available who can provide the services at issue in this appeal. 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 medical services provided to the enrollee by an out-of-network provider
on December 19, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that you are in a lot of pain. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services (CPT 81173) provided on November 17, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not a covered service.
The Plan must follow Medicare rules. Medicare rules say that the Group 3 CPT codes listed in A56199 are not medically necessary. We looked at the file and Medicare rules. The requested services, represented by CPT 81173, are considered not medically necessary according to A56199. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the lab services (CPT 81173) provided on November 17, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided on September 25, 2019.
You asked the Plan to pay for the physician services. You say that you would like the Plan to reconsider their
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
We looked at the file and Medicare rules. The file shows the claim was billed with an incorrect place of service
(POS) code per Medicare guidelines. The records show that the enrollee was transferred to the emergency
department when the services at issue were provided. Based on this information, we decided that Medicare
rules for coverage of the physician services have not been met. Therefore, we decided that the Plan does not
have to pay for the physician services provided on September 25, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on November 21, 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 there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a
physician.
We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation.
Based on this information, we decided that Medicare rules for coverage of these services have not been met.
Therefore, we decided that the Plan does not have to pay for the drug testing rendered on November 21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a hemodialysis procedure with single evaluation (90935)
provided on November 12, 2019.
You asked the Plan to pay for hemodialysis procedure with single evaluation. You say that this is supported.
The Plan denied your request. The Plan says this service is not documented on the billed date of service.
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 90935 is hemodialysis procedure with single evaluation
by a physician or other qualified health care professional.
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 hemodialysis procedure with single
evaluation. Our reviewer says that this code is not supported. Our physician reviewer found CPT 90935 should
only be reported if an evaluation of the patient is required and related to the hemodialysis procedure. The
evaluation documented in the submitted records is regarding hospital stay rather than hemodialysis.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of hemodialysis procedure with single evaluation have not been met. Therefore,
we decided that the Plan does not have to pay for a hemodialysis procedure with single evaluation (90935)
provided on November 12, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Quetiapine for the enrollee.
You asked the Plan to pre-approve this drug. You say that this has been helpful and stabilized the enrollee's mood and anxiety symptoms. The Plan denied your request. The Plan says that this is not covered under Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Quetiapine for the enrollee.
Benefits for this drug may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.